Incomplete eTAR Documentation for PRN Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident receiving PRN oxygen therapy. The resident, an older adult admitted with dementia and heart failure, had a care plan indicating oxygen therapy related to shortness of breath due to CHF, with interventions including reassurance, assistance via call system, and staying with the resident during episodes of respiratory distress. The resident’s MDS assessment documented oxygen therapy under Section O for special treatments and procedures. However, review of the resident’s eTAR for January 2026 showed an order for oxygen at 2–5 LPM via nasal cannula as needed for shortness of breath, but the eTAR lacked documentation of oxygen administration, including oxygen use, pulse, respiratory rate, and time completed. During interviews, the ADON stated that nurses were expected to document the resident’s oxygen status on the eTAR and not solely in the vital signs section, explaining that without eTAR documentation they would not know if the resident was using oxygen more regularly or needed it more than PRN. The Administrator confirmed that nursing staff were expected to document residents’ treatments on the corresponding eTAR and acknowledged that, in this case, documentation was present only under vital signs and not on the eTAR. The Administrator further stated that if a treatment was not documented, they would not be able to determine if the treatment was completed. The facility’s documentation policy stated that the facility would maintain complete and accurate documentation for each resident on all appropriate clinical record sheets, which was not followed in this instance.
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