Failure to Accurately Document Oxygen Therapy on MDS Assessment
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected a resident's status by not indicating that the resident received oxygen on her Quarterly MDS assessment. The resident, who had a history of acute respiratory failure with hypoxia, congestive heart failure, pneumonia, and high blood pressure, was observed and documented as receiving supplemental oxygen via nasal cannula. Her care plan included interventions for oxygen therapy, and vital sign records confirmed oxygen administration during the MDS look-back period. However, the MDS assessment did not reflect this, as the section for oxygen use was not checked. The MDS Nurse stated that she relied on the Medication Administration Records (MARs), which did not indicate oxygen use, and did not initially review the vital signs section that documented oxygen administration. Upon review, the MDS Nurse acknowledged the oversight and confirmed that the resident did receive oxygen during the look-back period. Interviews with facility leadership confirmed that the MDS Nurse was responsible for ensuring the accuracy of assessments, and that inaccurate documentation could result in an inaccurate plan of care.