Failure to Develop and Implement Complete Oxygen Therapy Care Plans
Penalty
Summary
The facility failed to follow and implement complete care plans for two residents with oxygen therapy needs. For one resident with emphysema/COPD, the care plan included an intervention for oxygen settings as ordered, but staff did not check or follow the care plan as required. The nurse responsible did not verify the care plan or ensure it was followed according to the physician's order for continuous oxygen at 2L/min, as confirmed by staff interviews and record review. The DON stated that her expectation was for nurses to follow doctor's orders, regulate oxygen or medication as ordered, and update the care plan to reflect any changes. For another resident, an unsecured oxygen tank was observed in the room, with no nasal cannula or nebulizer attached, despite a physician's order for oxygen therapy. Review of the care plan revealed that no care plan was in place for this resident's oxygen use. The MDS Director confirmed that the resident was ordered for oxygen at 2L/min and expected the care plan to contain accurate, resident-centered information. These findings indicate that the facility did not ensure care plans were developed and implemented to address all the residents' oxygen therapy needs.