Failure to Provide and Document Appropriate Respiratory Care for a Resident with COPD
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with its own policies, procedures, and standards of practice for a resident diagnosed with COPD and congestive heart failure. The resident was admitted and readmitted with these diagnoses, and the Minimum Data Set indicated intact cognition and no documented shortness of breath or respiratory treatments, including oxygen therapy. However, the Medication Administration Record did not show evidence that the resident received oxygen as needed over several days, despite a physician's order for oxygen therapy at 2L/min via nasal cannula as needed for COPD. This order lacked specific parameters for when to initiate, adjust, or discontinue oxygen therapy. Documentation was inconsistent and incomplete regarding the administration of oxygen. The Weights and Vitals Summary showed multiple instances where the resident was on oxygen, but the amount delivered was not specified. Nursing staff interviews confirmed that there was no documentation in the MAR or progress notes about when oxygen was started, the reason for its use, the resident's response, or when it was discontinued. There was also no evidence that the physician was notified about the resident's need for oxygen or that assessments were performed to determine the effectiveness or necessity of the therapy. The resident's care plan did not include specific goals or interventions related to respiratory care or oxygen therapy, despite the resident receiving oxygen. Facility policies required ongoing evaluation, documentation, and individualized care planning for residents with COPD, but these were not followed. Both the Registered Nurse Supervisor and the Interim Director of Nursing acknowledged the lack of adherence to facility policies and the absence of a resident-centered care plan for oxygen therapy, as well as insufficient documentation and communication with the physician.