Failure to Document Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that clinical records for a resident receiving oxygen therapy were properly completed in accordance with accepted professional standards and facility policy. The facility's policy requires that oxygen therapy be administered per physician's order and that the procedure be documented in the medical record. A resident with a diagnosis of Peripheral Vascular Disease was observed on multiple occasions to be receiving oxygen at 2 liters per minute via nasal cannula, as ordered by the physician. However, review of the Treatment Administration Record for the relevant month showed no initials or documentation indicating that oxygen was administered to the resident, despite direct observations and staff confirmation that the therapy was being provided.