Incomplete Documentation of Oxygen Administration in Medical Records
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented. Specifically, a review of the clinical record for a resident with heart disease, dementia, and asthma revealed a physician's order for continuous oxygen administration via nasal cannula at 4 liters per minute every shift. However, the medication administration record (MAR) for May did not include documentation that the resident received oxygen as ordered on multiple specified dates. The Nursing Home Administrator confirmed these findings, indicating that the facility did not maintain complete and accurate clinical records for this resident.