Inaccurate MDS Assessment of Oxygen Use
Penalty
Summary
Two residents with physician orders for oxygen therapy were not accurately assessed in their Minimum Data Set (MDS) documentation. Both residents had medical records, treatment administration records, and care plans indicating the use of oxygen, either at night or as needed, with specific instructions for oxygen administration and equipment maintenance. Despite this, their quarterly MDS assessments indicated that they were not using oxygen while in the facility. Interviews with staff, including a CNA and the DON, confirmed that both residents used oxygen at night and occasionally during the day. The MDS Coordinator, responsible for completing the assessments, acknowledged that the MDS entries for these residents were incorrect after reviewing the documentation and discussing the findings with the surveyor. The deficiency was identified through a combination of record review and staff interviews.