Inaccurate Documentation of Oxygen Saturations and Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident with chronic respiratory failure and hypoxia. The resident was admitted with this diagnosis and had physician orders in place from July through December for SpO2 monitoring every shift. Review of the resident’s oxygen saturation records from early September through mid-December showed multiple instances where documentation indicated the resident was receiving supplemental O2 at 2 to 5 LPM while simultaneously being documented as on room air, which indicates the resident was not actually receiving supplemental oxygen at those times. Record review identified seven such inaccurate entries in September, one in October, and two in December. During an interview, the Respiratory Therapist Manager stated that nursing staff are expected to document oxygen saturations accurately and should not document supplemental oxygen when the resident is on room air, and confirmed that the resident’s O2 saturation documentation had been inaccurate on multiple occasions. In a separate interview, the DON also confirmed that the resident’s O2 saturation documentation was not accurate and acknowledged it should have been accurate.
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