Failure to Accurately Document and Administer Supplemental Oxygen
Penalty
Summary
The facility failed to maintain accurate Medication Administration Records (MAR) and ensure proper administration of supplemental oxygen for two residents. For one resident, the physician's order specified oxygen at 2 liters per minute (L/min) via nasal cannula to maintain oxygen saturation at or above 92%, with administration and verification required every shift. However, the MAR was signed by a nurse who admitted she did not verify the oxygen flow rate on the concentrator before signing, and the staff schedule confirmed her assignment to the resident. The Director of Nursing (DON) confirmed that nurses are expected to verify and document the correct oxygen flow rate as per orders. For another resident, the order required continuous oxygen at 2 L/min with instructions to check the concentrator's function and setting every shift. Despite MAR documentation indicating the correct administration and verification, observations on two separate days revealed the oxygen concentrator was set at 3.5 L/min. A medication aide acknowledged she did not fully check the concentrator and was unaware of the incorrect setting. Additionally, a nurse confirmed she had not checked the concentrator that morning. The DON stated that only nurses should perform the required assessment and documentation, and that records must be complete and accurate.