Failure to Document Rationale for Oxygen Therapy
Penalty
Summary
The facility failed to document a rationale for the use of oxygen therapy for a resident with a diagnosis of chronic obstructive pulmonary disease (COPD). The resident was observed using oxygen in bed and reported using it most of the time due to COPD, but did not use oxygen during trips outside the facility for medical appointments. The physician's order for oxygen required staff to specify a diagnosis or reason for use, but the electronic health record and Medication Administration Record did not include documentation of the indication for oxygen therapy. Oxygen saturation levels for the resident were consistently above 92% both on oxygen and on room air. Licensed nursing staff and the Director of Nursing confirmed that all oxygen orders require a rationale for use and that the omission was a mistake. Facility policy also required oxygen to be administered as prescribed, with a documented purpose. The lack of documentation for the reason for oxygen use meant that staff would not know the intended purpose of the therapy, and the resident was not provided with oxygen during transportation to appointments, contrary to the physician's order.