Inaccurate Documentation of Medication and Oxygen Administration
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents regarding the administration of medications and oxygen therapy. For one resident with hypertension and heart failure, the Medication Administration Records (MAR) for July and August documented that Coreg was administered even when the resident's blood pressure was below the physician-ordered threshold of 150 mmHg. The nurse responsible for the documentation admitted that the records were incorrect and could not explain the discrepancies, confirming that the medication was not administered as recorded and that the MAR did not accurately reflect the resident's medication administration. Additionally, two residents with respiratory conditions requiring oxygen therapy had discrepancies between the physician's orders, the MAR, and actual observations. One resident with acute respiratory failure and asthma had a physician order for 3 liters per minute of oxygen, but was observed receiving 4 liters per minute, while the MAR reflected the ordered amount. Another resident with COPD and heart failure had a physician order for 2 liters per minute of oxygen, but was observed receiving 6 liters per minute, despite the MAR indicating the ordered amount. Staff interviews confirmed that the documentation did not match the observed oxygen settings, and the Director of Nursing acknowledged that staff should be verifying and documenting the correct oxygen flow rates each shift.