Inaccurate Documentation of Oxygen Cannula Changes
Penalty
Summary
The facility failed to ensure the accuracy of a medical record regarding the changing of oxygen nasal cannula tubing for a resident with chronic obstructive pulmonary disease (COPD). According to a physician's order, the resident's oxygen supplies were to be changed every seven days, with the date and initials recorded on the supplies. Review of the Medication Administration Record (MAR) indicated that the oxygen nasal cannula tubing was documented as changed on two specific dates by a nurse. However, during an observation, the tubing in use was labeled with a date that did not correspond to the documented change dates, suggesting the tubing had not been changed as recorded. Further investigation through staff interviews revealed that the nurse responsible for the documentation admitted to recording the tubing change on the MAR without actually performing the task on the specified dates. The nurse stated that the change was typically done at the end of the shift but acknowledged it may have been forgotten on those occasions. Both the Director of Nursing and the Administrator confirmed that documentation should not have indicated the tubing was changed if the task was not completed as ordered.