Failure to Accurately Maintain Medical Records for Oxygen Administration and AIMS Assessments
Penalty
Summary
The facility failed to accurately maintain medical records in accordance with accepted professional standards for two residents. For one resident with chronic obstructive pulmonary disease (COPD), the care plan and physician's order specified oxygen at 2 liters per minute (LPM). However, surveyor observations on multiple occasions found the resident receiving approximately 3.5 LPM of oxygen, while the Medication Administration Records (MARs) inaccurately documented administration at 2 LPM. A registered nurse also documented the ordered rate despite observing a different rate earlier in the day and could not explain the discrepancy during an interview. For another resident with a history of anxiety, bipolar disorder, PTSD, and panic disorder, the care plan required regular Abnormal Involuntary Movement Scale (AIMS) assessments as directed by a physician's order. Although records indicated that AIMS assessments were completed on specific dates, further review revealed that the last actual assessment was completed prior to those dates, and there was no evidence to support the documented completion of the assessments. The Director of Nursing Services was unable to provide accurate records for these assessments during the surveyor interview.