F0842

E

Incomplete Clinical Records for Oxygen Therapy and TB Testing

Tipton, Indiana Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate clinical records for multiple residents, including missing and incomplete documentation of oxygen therapy and tuberculosis (TB) testing. For one resident with acute respiratory failure, heart failure, RSV pneumonia, pneumonia of the left lower lobe, and acute hypoxic respiratory failure, the hospital discharge paperwork indicated the resident was using 2 L of oxygen via nasal cannula at discharge. A written physician telephone order dated the same day directed oxygen at 2 L/min as needed for shortness of breath, but this order lacked the nurse’s signature, date, and time of receipt and was never entered into the electronic health record. Although the admission assessment, post‑admission assessment, care plan, and occupational therapy evaluation all referenced oxygen use at 2 L via nasal cannula, the electronic record contained only intermittent oxygen saturation entries, some on room air, and transfer documentation related to a later respiratory arrest left the respiratory device and oxygen use sections blank. Staff interviews confirmed that an oxygen order should have been present and that the DON could not explain why it was missing, while the unit manager gave conflicting information about whether the resident was discharged with an oxygen order.

The facility also failed to maintain complete TB testing documentation for several residents. One resident’s electronic medical record initially contained no TB testing information until it was added later, and even then the record did not show the times the tests were administered or read, nor the dates the tests were read. The ADON/Infection Preventionist stated that TB tests must be read within 48–72 hours and that the medical record should include the date and time the tests were given and read, but this information was not present in the record.

For two additional residents, TB testing records were incomplete or inconsistent. One resident’s testing record showed TB tests given on two dates at “midnight,” with no indication of the date or time either test was read. Another resident’s admission TB tests were documented as given on two separate dates, but the clinical record did not include the date or time either test was read. An immunization report later provided showed different TB test dates for this resident, and still did not include the date or time the tests were read. The facility did not provide an admission TB policy, and the existing nursing documentation guideline emphasized being definite, using quantifiable data, and timely documentation, stating that if something was not written down, it was not done.