Failure to Accurately Document Oxygen Therapy in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident who was prescribed oxygen therapy. The resident, a female with multiple diagnoses including COPD, muscle wasting, dysphagia, hypertension, peripheral vascular disease, and gout, had a physician's order for oxygen at 2LPM via nasal cannula as needed for shortness of breath. Although the resident's care plan and skilled nurse notes consistently indicated that she was receiving oxygen therapy, there were no corresponding administration entries documented in the Medication Administration Record (MAR) for several consecutive days. Interviews with nursing staff and facility leadership confirmed that oxygen therapy was being administered but not recorded in the MAR as required by facility policy. The nurse responsible for the resident was unaware that documentation in the MAR was necessary for as-needed oxygen administration, and the Assistant Director of Nursing acknowledged that the omission was not detected during routine MAR reviews. Facility policies reviewed stated that all administered medications and treatments, including vital signs when required, must be accurately documented in the MAR to reflect the resident's actual experiences and care provided.