Failure to Document Oxygen Tubing Changes in Medical Record
Penalty
Summary
Facility nurses failed to document their initials on the medication administration record after changing a resident's oxygen tubing and nasal cannula as ordered. Specifically, for one resident with multiple diagnoses including osteomyelitis of the vertebra, discitis, heart failure, hypertension, muscle weakness, urinary tract infection, and cirrhosis of the liver, the treatment administration record for the month showed blank entries on the scheduled dates for changing the oxygen tubing and nasal cannula. Observation confirmed that the tubing and cannula had been changed and labeled accordingly, but the required documentation was missing. Interviews with the ADON and DON confirmed that the night nurses performed the changes but did not document them, and that there was no specific facility policy regarding documentation of this task. However, both acknowledged that documentation should have occurred to maintain accurate medical records and ensure communication among nursing staff. This lack of documentation resulted in incomplete medical records for the resident.