Failure to Accurately Document Oxygen Administration
Penalty
Summary
The facility failed to maintain accurate medical records regarding the administration of oxygen for a resident with a tracheostomy. The physician's order specified that the resident should receive 4 liters of oxygen per minute via tracheostomy to maintain oxygen saturation above 90%. However, repeated observations over several days showed the resident was receiving oxygen at 3 liters per minute via nasal cannula, not via tracheostomy as ordered. The resident was not in respiratory distress during these observations and confirmed that the correct rate should be 4 liters. Documentation in the Medication Administration Record (MAR) by the assigned nurse indicated that the resident was receiving 4 liters per minute via tracheostomy, consistent with the physician's order, even though the actual administration was 3 liters per minute via nasal cannula. The nurse acknowledged that she documented the ordered method and rate rather than the actual method and rate being used. Both the Director of Nursing and the Administrator confirmed that the nurse should have contacted the medical provider to update the order to reflect the resident's preference and actual practice, rather than inaccurately documenting compliance with the original order.