Resident 39 provides the clearest example of this documentation failure. On September 15, Medication Aide 1 recorded in the resident's chart that he received 3 liters of oxygen via nasal cannula, with an oxygen saturation of 97 percent. But when inspectors observed the resident in his room that morning at 8:44 am, his oxygen concentrator was set to 4 liters per minute.
The medication aide confirmed the discrepancy during questioning. At 1:15 pm on September 15, she told inspectors she was responsible for Resident 39 during the day shift from 7:00 am until 3:00 pm. She acknowledged that the oxygen concentrator read 4 liters per minute and stated she documented it at 4 liters per minute. Yet her written record showed 3 liters.
Resident 91 experienced an even more dramatic gap between documented and actual oxygen delivery. This resident was admitted with chronic obstructive pulmonary disease, altered mental status, chronic systolic heart failure, and wheezing. A physician's order dated July 5, 2024 specified oxygen at 2 liters per minute via nasal cannula for hypoxia.
Nurse 2 documented in Resident 91's September medication record that the patient received 2 liters of oxygen via nasal cannula during each shift on September 14, with recorded oxygen saturations of 97 percent. But inspectors found the resident's oxygen concentrator set to 6 liters per minute during two separate observations that day, at 9:22 am and again at 1:45 pm.
The resident was receiving three times the documented dose.
When contacted by phone on September 17 at 4:15 pm, Nurse 2 confirmed she was responsible for Resident 91 during the night shift from 7:00 pm to 7:00 am. She stated she documented that Resident 91 was on 2 liters per minute in the medication administration record. She offered no explanation for why the machine was set to 6 liters.
The Director of Nursing acknowledged the systemic nature of the problem during her September 15 interview at 2:02 pm. She told inspectors that nursing staff should be reading physician orders and checking oxygen concentrators for the correct liters per minute setting every shift for accurate documentation.
Her statement revealed that staff were not following this basic protocol.
For residents with COPD and heart failure, oxygen levels require precise management. Too little oxygen can worsen breathing difficulties and strain the heart. Too much oxygen can suppress the breathing drive in COPD patients, potentially creating dangerous complications.
The documentation errors also compromise continuity of care. When nurses record incorrect oxygen levels, incoming staff cannot make informed decisions about patient needs. Physicians reviewing charts see inaccurate data about how patients respond to treatment.
The inspection identified this as a medication administration violation affecting multiple residents. Both cases involved patients with serious respiratory and cardiac conditions who required careful oxygen management as part of their treatment plans.
Resident 39's case showed a medication aide documenting one dose while the patient received a higher amount. Resident 91's situation was more concerning, with actual oxygen delivery triple the physician-ordered dose and documented amount.
The facility's own nursing director confirmed that staff should check oxygen concentrator settings every shift and document accurately. This basic safety check was not happening consistently, creating a pattern of unreliable medication records.
Both residents had oxygen saturations recorded at 97 percent despite receiving different actual doses than documented. This suggests staff may have been recording routine vital signs without verifying the accuracy of the underlying treatment delivery.
The September inspection found these documentation failures during routine observations of residents in their rooms. The discrepancies were immediately apparent to inspectors who compared written records to actual machine settings.
For Resident 91, the gap between ordered treatment, documented care, and actual delivery created multiple layers of potential risk. The physician ordered 2 liters, the nurse documented 2 liters, but the machine delivered 6 liters to a patient with COPD and heart failure.
The facility received a minimal harm citation, but the violation affected multiple residents and revealed systematic failures in medication administration oversight. Staff were not following their own director's stated protocols for verifying and documenting oxygen therapy.
Neither the medication aide nor the nurse offered explanations for why their documentation differed from the actual machine settings they were responsible for monitoring and recording.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mount Olive Center from 2025-10-01 including all violations, facility responses, and corrective action plans.