Failure to Accurately Document Oxygen Therapy on MDS Assessment
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected a resident's status by not indicating that the resident received oxygen therapy on the Quarterly MDS assessment. The resident, who had a history of acute respiratory failure with hypoxia, congestive heart failure, pneumonia, and high blood pressure, was observed and documented as receiving supplemental oxygen via nasal cannula. The care plan included interventions for oxygen therapy, and the electronic clinical record showed oxygen administration during the MDS look-back period. However, the MDS assessment did not reflect this, as the section for oxygen use was not checked. The MDS Nurse stated that the omission occurred because she relied on the Medication Administration Records (MARs), which did not indicate oxygen administration, rather than reviewing the vital signs section that documented oxygen use. Upon review, the MDS Nurse acknowledged that the resident did receive oxygen during the look-back period and that the MDS should have been marked accordingly. Interviews with facility leadership confirmed that the MDS Nurse was responsible for ensuring assessment accuracy and that an inaccurate MDS could result in an inaccurate plan of care.