Failure to Maintain Accurate Medical Records for Oxygen and Respiratory Therapy
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was administered supplemental oxygen via nasal cannula, CPAP, and BiPAP without a corresponding physician's order. The resident, a male with multiple diagnoses including cellulitis, peripheral vascular disease, congestive heart failure, Type II diabetes, and morbid severe obesity with alveolar hypoventilation, was admitted with hospital discharge instructions for supplemental oxygen and CPAP use. However, upon review, there were no physician's orders for these treatments in the resident's consolidated orders or treatment administration records. Nursing progress notes documented the administration of oxygen at various flow rates and the use of CPAP and BiPAP, but these interventions were not supported by written or signed physician orders in the resident's medical record. Interviews with nursing staff revealed that they typically relied on physician orders or would contact the physician if an order was missing, but in this case, the need for an order was overlooked. The Director of Nursing and the Administrator both acknowledged that the process for transcribing and obtaining physician signatures for verbal or telephone orders was not followed as required by facility policy. Facility policies reviewed indicated that verbal and telephone orders must be promptly documented, transcribed into the resident's medical record, and countersigned by the physician during their next visit. In this instance, the failure to properly document and obtain physician authorization for the administration of oxygen therapy and respiratory support devices resulted in incomplete and inaccurate medical records for the resident.