Failure to Maintain Accurate Medical Records for Oxygen Therapy and Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, there were two active physician orders for oxygen therapy at different flow rates (2 liters and 3 liters per minute via nasal cannula), both of which remained active in the medical record. Medication administration records (MARs) reflected both orders, and staff documented administration for both, despite the resident only receiving oxygen at 2 liters per minute. The nurse responsible for entering the new order did not discontinue the previous order, and staff did not seek clarification about the conflicting orders. For another resident, wound care was not provided as ordered over a weekend, but the MAR was inaccurately documented to indicate that the treatment had been completed. The unit manager checked off the treatment as completed based on verbal confirmation from the assigned nurse, who later admitted to having overlooked the treatment. The resident confirmed that the wound dressing had not been changed as required, and the wound nurse verified that the same bandage was in place from a previous date. Documentation was completed by a nurse who did not perform the treatment, resulting in inaccurate medical records.