Failure to Accurately Document Oxygen Therapy on MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's needs by not reflecting the resident's current oxygen therapy on the Minimum Data Set (MDS). The resident, who was admitted with diagnoses including dementia, epilepsy, aphasia, and dysphagia, had severely impaired cognitive skills and was dependent on staff for all activities of daily living. Despite having a physician's order for oxygen at two liters per minute via nasal cannula every shift, and documentation on the Medication Administration Record confirming daily administration of oxygen, the MDS did not indicate that the resident was receiving oxygen therapy. During interviews, the MDS nurse acknowledged that the omission was an error and stated that the resident's oxygen therapy should have been included in the MDS to accurately reflect the resident's respiratory treatment. The MDS Nurse Supervisor also confirmed the importance of the MDS as an accurate representation of the resident's assessments, care planning, treatments, and interventions. Review of facility policy indicated that the Resident Assessment Instrument (RAI) process is to be used as the basis for accurate assessment of each resident's functional capacity and health status.