Failure to Accurately Document Oxygen Device Used During Resident Emergency
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by incorrectly documenting the type of oxygen device used during a critical event. The resident, who had severe cognitive impairment and required moderate assistance with daily activities, experienced desaturation and chest congestion. Documentation in both the Change in Condition Evaluation and Progress Notes indicated that 15 liters of oxygen were administered via a face mask. However, interviews with nursing staff and the Director of Staff Development revealed that a face mask can only deliver up to six liters of oxygen, and that 15 liters should be administered using a non-rebreather mask. The registered nurse involved later confirmed that she had used a non-rebreather mask but documented it incorrectly as a face mask. This inaccurate documentation was acknowledged by both the nurse and the Director of Nursing, who emphasized the importance of precise record-keeping to reflect the actual interventions provided during episodes of low oxygen saturation. The facility's policy on nursing documentation requires that records be concise, clear, pertinent, and accurate, but this standard was not met in this instance, resulting in a medical record that did not accurately communicate the care provided to the resident.