Inaccurate Documentation of Oxygen Therapy Treatments
Penalty
Summary
Nursing staff failed to accurately document the provision of oxygen therapy treatments for two residents. In one case, a resident was observed receiving oxygen therapy with a humidifier bottle and nasal cannula tubing that were both dated to indicate they had last been changed several weeks prior, despite physician orders requiring weekly changes. The Treatment Administration Record showed staff initials and checkmarks indicating the treatments had been completed on the scheduled dates, but physical evidence contradicted this documentation, as the humidifier bottle was completely dry and had not been changed as recorded. In another instance, a second resident was also observed receiving oxygen therapy with equipment that was not dated to indicate when it had last been changed, despite orders for weekly changes. The Treatment Administration Record again showed staff initials and checkmarks for completed treatments, but the condition of the equipment suggested otherwise. The DON confirmed that the documentation was inaccurate and that the initials were from agency nurses. Facility policies require that all treatments and services provided to residents be completely and accurately documented in the medical record, including the date, time, and name of the nurse performing the procedure.