Failure to Accurately Document Oxygen Administration in MAR
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with diagnoses of COPD and Alzheimer's Disease. Specifically, the Medication Administration Record (MAR) did not reflect the administration of oxygen therapy on nine occasions during August, despite other documentation and staff interviews confirming that the resident received oxygen via nasal cannula on those dates. The resident had an active physician order for oxygen at 2 liters/minute as needed for shortness of breath, which was not properly documented in the MAR. Interviews with the ADON and DON confirmed that the resident intermittently used oxygen, particularly after an episode of shortness of breath, and that it was the responsibility of nursing staff to document all medication and treatment administration in the MAR. Facility policy also required documentation of all administered medications and treatments. The lack of accurate documentation in the MAR resulted in incomplete clinical records for the resident.