Inaccurate Oxygen Therapy Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure accurate data entry in a resident's medical record, specifically for a resident with chronic congestive heart failure and chronic obstructive pulmonary disease. The resident had a physician's order for BIPAP with home settings and oxygen at 2 liters with humidification. However, multiple entries in the resident's medical record documented the use of oxygen via nasal cannula, which was inconsistent with the physician's order and the actual care provided. These entries were made by various nursing staff over a period of time. Upon review, it was observed that there was no nasal cannula present in the resident's room, and the Chief Nursing Officer confirmed that the oxygen order was for use with BIPAP only. The Clinical Registered Nurse acknowledged that the documentation of oxygen via nasal cannula was a documentation error and should have been identified and corrected. This inaccurate documentation resulted in the resident's medical record not reflecting the actual care provided.