Failure to Accurately Document and Code Oxygen Therapy on MDS
Penalty
Summary
Facility staff failed to ensure that clinical records for a resident were accurately documented in accordance with accepted professional health information management standards. Specifically, the facility did not properly code the resident's oxygen treatment on the Minimum Data Set (MDS), despite the resident having physician orders for PRN oxygen therapy due to respiratory conditions and being on hospice care. The resident's care plan and physician orders indicated the need for oxygen therapy, and staff were expected to document administration and refusals, as well as notify appropriate personnel when the resident refused treatment. Record reviews revealed that the resident had a history of refusing care and treatment, including oxygen therapy. Interviews with facility staff, including the Hospice RN, NP, ADON, DON, and MDS coordinators, confirmed that the resident had an active order for PRN oxygen and that refusals were to be documented and reported. However, during the lookback period for the MDS, the resident had not received oxygen treatment, and the last documented administration was prior to the most recent physician order. The Treatment Administration Record (TAR) did not reflect any oxygen administration during the relevant period, and the MDS was not coded to indicate oxygen therapy. Additionally, the facility was unable to provide its MDS policy protocol when requested by the surveyor, despite assurances that it would be sent. The administrator acknowledged awareness of the resident's resistance to care and stated that staff were expected to follow facility policy and physician orders. The failure to accurately document and code the resident's oxygen therapy on the MDS constituted a deficiency in maintaining clinical records according to professional standards.