Failure to Document Oxygen Administration in MAR
Penalty
Summary
The facility failed to document the administration of oxygen therapy for a resident with chronic respiratory failure and chronic obstructive pulmonary disease, as required by physician orders and facility policy. Although the resident had a physician's order for oxygen via nasal cannula at three liters per minute as needed for shortness of breath, the medication administration records (MARs) for May, June, and July did not contain any documentation of oxygen administration. Observations showed the resident wearing oxygen via nasal cannula on multiple occasions, with the oxygen concentrator set to two liters per minute. The resident reported wearing oxygen continuously and stated that all oxygen was administered by facility staff. Interviews with an LPN and the interim DON confirmed that oxygen was being administered but not documented in the electronic health record. The DON acknowledged that oxygen is considered a medication and should be documented on the MAR at the time of administration, in accordance with facility policy. The lack of documentation was confirmed by both the LPN and the DON, who stated that there was no record of oxygen administration for the resident during the three-month period reviewed.