Failure to Maintain Accurate Medical Records for Oxygen Therapy
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident. A review of the resident's electronic medical record showed documentation indicating the resident had a physician's order for oxygen therapy via nasal cannula at 2 liters per minute, and that the resident was educated on the importance of complying with these oxygen orders. The medical record also included notes stating the resident was non-compliant with oxygen therapy and had received education about it. However, a review of the resident's physician orders revealed there was no order for oxygen therapy at any time. Interviews with the Director of Nursing confirmed that the resident never had a physician's order for oxygen. The documentation in the medical record was therefore false and did not meet the facility's policy requirements for accuracy, relevance, and completeness. The resident involved had multiple complex medical diagnoses, including type II diabetes, acute kidney failure, congestive heart failure, and other chronic conditions, and was noted to be moderately cognitively impaired at the time of the incident.