Failure to Accurately Document Oxygen Therapy Administration
Penalty
Summary
The facility failed to maintain accurate medical records for one resident by not properly documenting the administration of oxygen therapy. The resident, who had diagnoses including sepsis, dysphagia, muscle weakness, and COPD, had a physician's order for oxygen at 2 liters via nasal cannula as needed. However, during multiple observations and interviews, it was found that there was no oxygen set up or available at the resident's bedside, and several nurses confirmed that oxygen was not administered during the reviewed period. Despite this, the Medication Administration Record (MAR) indicated that oxygen was administered to the resident from the 1st to the 6th of the month. Multiple licensed nurses acknowledged that they did not administer the oxygen, yet the MAR reflected otherwise, indicating inaccurate documentation by at least six licensed nurses. The facility's policy requires nursing documentation to be concise, clear, pertinent, and accurate, which was not followed in this instance.