Failure to Maintain Accurate and Complete Medical Records for Oxygen Administration
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that resident records were accurate and complete for a resident who was transferred to the hospital due to shortness of breath. Review of the clinical record showed that the resident experienced a change in condition and was given new orders for oxygen and other treatments by the on-call provider. Documentation from an LPN indicated that PRN oxygen at two liters per minute was administered. However, further review of the resident's medical record did not reveal any physician's order for the oxygen use. The Director of Nursing confirmed that no such order was entered into the resident's medical record.