Failure to Follow Comprehensive Care Plans for Respiratory, Oxygen, and Contracture Management
Penalty
Summary
The facility failed to follow comprehensive, person-centered care plans for three residents, resulting in deficiencies related to respiratory care, oxygen therapy, and contracture management. For one resident with COPD, observations revealed that the nebulizer mask was left unbagged on the overbed table, and the resident self-administered nebulizer treatments without a physician's order or assessment for self-medication. The nurse did not remain with the resident during the treatment, and the oxygen concentrator was set below the physician-ordered rate on multiple occasions. The care plan required staff to administer medications and oxygen as ordered, and to monitor lung sounds, but these interventions were not consistently followed. Another resident receiving oxygen therapy via nasal cannula was observed multiple times with the oxygen concentrator set below the physician-ordered rate of 2 liters per minute. Documentation in the Treatment Administration Record was incomplete, with several shifts lacking evidence that oxygen therapy was monitored as required. The care plan for this resident included interventions to provide oxygen as ordered, but these were not consistently implemented, as confirmed by staff interviews and record review. A third resident with severe cognitive impairment and upper extremity contractures was not observed wearing prescribed splints or orthotics during multiple visits, and no such devices were visible in the room. Staff interviews revealed a lack of awareness regarding the resident's need for splints/orthotics, and review of the care plan and physician's orders confirmed that the resident was to wear specific splints and a palm guard for a set duration each week. There was no documentation of the resident receiving assistance with these devices or of any refusals, indicating that the care plan interventions were not followed.