Oxygen Therapy Provided Without Physician Order
Penalty
Summary
The facility failed to ensure a resident received appropriate respiratory care when the resident was provided oxygen therapy without a physician’s order. The resident, who had diagnoses including heart failure and sleep apnea, was observed lying in bed wearing a nasal cannula with oxygen flowing at 3 LPM. A review of the resident’s physician orders on that date did not show any order for oxygen via nasal cannula at 3 LPM. During an interview, a licensed nurse confirmed there was no oxygen order for the resident and acknowledged that an order was required. Further investigation by the DON revealed that the resident had requested oxygen therapy via nasal cannula from a staff member several days earlier, and the staff member provided the oxygen without first obtaining a physician’s order. At the time of the surveyor’s observation, the resident continued to receive oxygen at 3 LPM despite the absence of an order in the medical record. The report states that this failure had the potential to negatively affect the resident’s health and well-being, including possible lung and brain damage related to unordered, unmonitored oxygen therapy.
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