Inaccurate MDS Assessment for Oxygen Therapy
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one resident with multiple respiratory diagnoses, including pulmonary embolism, acute respiratory failure with hypoxia, pulmonary fibrosis, pulmonary hypertension, and atelectasis. The resident was admitted with a history of hypoxia and required supplemental oxygen, as documented in both nursing and physician progress notes, as well as through interviews with the resident and multiple LPNs who confirmed the use of nighttime oxygen since admission. Despite this, the MDS assessment did not reflect the use of supplemental oxygen under Section O0110, Special Treatments, Procedures, and Programs. Review of the resident's active orders showed a directive for nursing to manage oxygen administration in coordination with the physician, but there was no specific physician order detailing when or at what flow rate the oxygen should be administered. The MDS Coordinator acknowledged that the omission of oxygen therapy on the MDS was an error that should have been identified during routine audits. The Director of Health Services and the Executive Director both stated their expectations for accurate and thorough completion of MDS assessments, but the deficiency was not detected prior to the survey.