Failure to Accurately Document Oxygen Therapy in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents who were receiving oxygen therapy. For both residents, the MDS assessments did not document their ongoing oxygen use, despite evidence from care plans, physician orders, and treatment administration records indicating that oxygen therapy was being provided. The omission was identified through observations, interviews, and record reviews conducted by surveyors. One resident, a female with a diagnosis of chronic obstructive pulmonary disease (COPD), had a care plan and physician orders specifying oxygen therapy via nasal cannula at 2 liters per minute as needed. Her care plan included detailed interventions for monitoring respiratory status and safety precautions related to her smoking history. However, her comprehensive MDS assessment did not indicate that she was receiving oxygen therapy during the look-back period, even though her care plan and other records confirmed its use. Another resident, a male also diagnosed with COPD, had physician orders for continuous oxygen via nasal cannula, with instructions to titrate the flow rate and monitor oxygen saturation. His care plan and treatment administration records documented regular maintenance and monitoring of his oxygen equipment. Despite this, his MDS assessment left the section for special treatments, including oxygen therapy, blank. Interviews with facility staff, including the DON and MDS coordinator, confirmed that the MDS assessments were completed without reflecting the residents' actual oxygen use.