Failure to Document and Assess Oxygen Self-Administration
Summary
The facility failed to ensure proper documentation and assessment related to oxygen administration for two patients. Specifically, the Medication Administration Records (MARs) for both patients did not include a section for licensed nursing staff to document the administration of oxygen, despite physician orders allowing the patients to use oxygen at specified rates via nasal cannula. The Director of Nursing Services confirmed that there was no place in the MARs for this documentation. Additionally, the facility did not conduct formal assessments to determine the patients' ability to safely self-administer oxygen, nor did it provide formal education to the patients regarding self-administration, as required by facility policy. Both patients involved had a diagnosis of schizoaffective disorder and were assessed as cognitively intact based on their Brief Interview for Mental Status (BIMS) scores. The facility's policies required interdisciplinary team assessments of cognitive, physical, and visual abilities for self-administration of medications, as well as patient instruction and demonstration of self-administration skills. These steps were not completed for either patient, resulting in incomplete health records and a lack of formal verification of their ability to self-administer oxygen safely.
Plan Of Correction
The facility recognizes the importance of maintaining complete and accurate health records. June 27, 2025. The facility shall continue to maintain complete and accurate health records. For Resident 3 and Resident 5, the oxygen administration was documented on MAR June 4, 2025. Formal education regarding self-administration of oxygen was completed on June 4, 2025, by the Clinical Nurse, and assessments will be performed by the Clinical Nurse Supervisor by July 15, 2025. The DNS, Clinical Care Manager, Director of Staff Development, LN Shift Supervisors, Medical Records Supervisor, and Nursing staff shall be responsible for the correction. Newly admitted patients with supplemental oxygen orders will have a self-administration evaluation assessment completed upon admission. Education on self-administration of supplemental oxygen will be provided upon admission. Residents with supplemental oxygen orders will have a self-administration evaluation assessment completed at least quarterly by licensed staff. Education on self-administration of supplemental oxygen will be provided at least quarterly, by licensed staff. Further issues regarding the content of health records and documentation of oxygen administration will be received during the QA process and brought to the QAPI Committee for review at least quarterly, or with more frequency if an issue is identified. The Clinical Care Manager, DSD, DNS, Medical Director, Nurse Shift Supervisors, Nursing staff, Medical Records Supervisor, and Administrator shall be responsible to monitor for ongoing compliance. This page is purposefully left blank. This page is purposefully left blank.
Penalty
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