Failure to Document PRN Oxygen Administration and Assessment
Penalty
Summary
The deficiency involves the facility’s failure to accurately and completely document the administration of oxygen therapy and related assessments for one resident, as required by facility policy and professional standards. The resident was admitted with chronic lymphocytic leukemia of B-cell type not in remission and malignant neoplasm of the prostate, and was assessed on the MDS as cognitively impaired with a need for partial/moderate assistance for oral, toilet, and personal hygiene. The resident had an order, dated 1/23/2026, for oxygen at 2–4 L/min via nasal cannula or 5–10 L/min via mask to maintain O2 saturation ≥ 92%, with a requirement to record O2 saturation before administration. On the date of the incident, the MAR for the resident showed the PRN oxygen order but was blank for any oxygen administration on that day, and the SBAR communication form completed that afternoon did not indicate that oxygen had been given when the resident was found unresponsive. During a concurrent review of the MAR and SBAR, the LVN reported that at approximately 3:30 PM he administered oxygen at 10 L/min via mask to the resident upon finding him unresponsive but forgot to document this on both the MAR and the SBAR, and also did not record the O2 saturation as required. The facility’s Charting and Documentation policy stated that all services provided and any changes in the resident’s condition must be documented in the medical record to facilitate communication among the interdisciplinary team, which was not followed in this instance.
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