Inaccurate Documentation of Oxygen Tubing and Humidifier Change
Penalty
Summary
A deficiency occurred when a nurse inaccurately documented the completion of changing a resident's oxygen tubing and water in the medical record, despite not having performed the task. The resident, an elderly female with diagnoses including respiratory failure, pneumonia, COPD, and heart failure, was receiving oxygen therapy as ordered. Documentation in the Treatment Administration Record (TAR) indicated that the oxygen tubing was changed on a specific date, but an observation revealed that the water bottle attached to the oxygen concentrator was empty and had not been changed since a prior date. Interviews with nursing staff and the interim Director of Nursing confirmed that the nurse's signature on the MAR was intended to indicate both the tubing and water had been changed, which was not the case. Facility policy required that all services provided to residents be documented in the medical record, and that oxygen humidifiers be checked and changed as needed. However, the policy did not specifically address the accuracy of documentation. The failure to accurately document the completion of required care tasks resulted in incomplete and inaccurate medical records for the resident.