Incomplete Oxygen Therapy Documentation and Mismatched Orders
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for residents receiving oxygen therapy, specifically related to documentation of oxygen concentrator flow rates and accurate transcription of physician and hospice admission orders. For one resident with chronic respiratory failure with hypoxia and simple chronic bronchitis, the physician’s order dated 08/21/24 specified oxygen via nasal cannula at 1–2 LPM. However, multiple entries of oxygen saturation documentation between 12/02/25 and 12/10/25 recorded oxygen saturation values and noted use of a nasal cannula, but did not include the oxygen concentrator rate on any of the documented occasions. For another resident with COPD, chronic respiratory failure with hypoxia, a solitary pulmonary nodule, and dependence on supplemental oxygen, hospice admission orders dated 11/12/25 directed oxygen via nasal cannula at 8–10 LPM. A subsequent physician order dated 11/13/25 in the medical record instead specified oxygen via nasal cannula at 6–8 LPM for COPD, which did not match the hospice admission orders. In addition, oxygen saturation documentation for this resident from 11/17/25 to 11/30/25 repeatedly recorded oxygen saturation levels and indicated use of a nasal cannula, but on each listed entry staff failed to document the oxygen concentrator rate. A third resident with chronic respiratory failure had admission orders dated 12/05/25 for continuous oxygen starting at 2 LPM with increases as needed to keep oxygen saturation greater than 90%. A physician’s order dated the same day in the medical record instead directed to increase oxygen requirement by 2 LPM to keep oxygen saturations greater than 90%, which did not match the admission order to start at 2 LPM. Oxygen saturation documentation for this resident from 12/05/25 to 12/11/25 showed multiple entries where staff recorded oxygen saturation values and noted use of a nasal cannula, but did not document the oxygen concentrator rate. During an interview on 12/11/25, the ADON confirmed that the hospice admission orders and medical record orders for one resident did not match, the admission and medical record orders for another resident did not match, and that staff did not document oxygen concentrator rates for the three residents when documenting oxygen saturations, despite the expectation that staff correctly enter orders and document oxygen concentrator rates in the medical record.
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