Failure to Provide Ordered Continuous Oxygen and Falsification of MAR Documentation
Penalty
Summary
Surveyors determined that the facility failed to provide respiratory services in accordance with professional standards of practice for one resident who had a physician’s order for continuous oxygen. The resident had an order written on 2/24/26 for oxygen at 2 liters continuous for comfort every shift. During multiple observations over three consecutive days, surveyors repeatedly observed the resident lying in bed with an oxygen concentrator present in the room but turned off, and the nasal cannula coiled and resting on top of the concentrator under the handle, not in use. At no time during these observations was the resident seen receiving oxygen. Review of the resident’s March 2026 MAR showed that nurses had initialed each shift on the dates in question, documenting that the resident was receiving oxygen around the clock as ordered. The initials belonged to six different licensed nurses, indicating that each had recorded that oxygen was being administered when, based on surveyor observations, it was not. On 3/11/26, the DON and Nursing Home Administrator were informed that these six licensed nurses had falsified the medical record by documenting that the resident was receiving oxygen each shift when the oxygen concentrator was off and the nasal cannula was not applied. The DON later confirmed these findings.
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