Failure to Transcribe Oxygen Order Accurately
Penalty
Summary
The facility failed to provide services that met professional standards by not accurately transcribing a physician's order for a resident's oxygen therapy. The resident, who was admitted with diagnoses including congestive heart failure, atrial fibrillation, and coronary artery disease, was on hospice care and required supplemental oxygen for comfort. Despite having an order for oxygen therapy, the facility did not include this order in the Medication Administration Records (MAR) for March and April 2025, nor was it present in the signed Physician's Order Summary. This oversight resulted in the resident's oxygen usage not being documented as required. Observations and interviews revealed discrepancies in the facility's awareness and documentation of the resident's oxygen use. A portable oxygen concentrator was observed in the resident's room, and the resident confirmed using oxygen as needed. However, the Co-Directors of Nursing were unaware of the resident's oxygen use and the presence of an oxygen concentrator in the room. The facility's failure to transcribe the oxygen order accurately onto the MARs and the Physician's Order Summary led to a deficiency in meeting professional standards of care.