Inaccurate Resident Assessment for Oxygen Therapy
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for one resident receiving respiratory services. Specifically, the Minimum Data Set (MDS) quarterly assessment documented that the resident did not use oxygen therapy, despite multiple records showing the resident was receiving oxygen via nasal cannula on several occasions. Nurses' notes and vital sign records consistently indicated oxygen use, and a physician's order was in place for oxygen administration as needed for shortness of breath. During an interview, an LPN acknowledged that the MDS section regarding oxygen use needed updating and that nursing staff were not documenting oxygen therapy on the treatment record, instead recording it in nurses' notes and vital sign records. The facility's policy requires comprehensive and accurate assessments using the RAI process, which was not followed in this instance.