Failure to Develop Comprehensive Care Plans for Oxygen Therapy and Indwelling Catheter
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific medical needs. One resident, admitted with diagnoses including Parkinson's disease, hypertension, anxiety disorder, and depression, had a physician's order for oxygen therapy via nasal cannula as needed for shortness of breath, wheezing, or oxygen saturation below 92%. Despite documentation in the electronic medical record and the Minimum Data Set indicating the use of oxygen therapy, the resident's care plan did not reflect this intervention. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the care plan did not address the resident's oxygen use, contrary to facility policy requiring comprehensive, person-centered care plans based on resident assessments. Another resident, admitted with conditions such as a displaced femur fracture, chronic kidney disease, and cystitis with hematuria, had a physician's order for an indwelling Foley catheter for urinary retention. The Minimum Data Set also indicated the presence of the catheter, but the resident's care plan did not include this intervention. The MDS Coordinator acknowledged responsibility for updating care plans and confirmed the omission, as did the Director of Nursing. These findings were based on record reviews, staff interviews, and facility policy review, demonstrating a failure to ensure care plans addressed all identified care needs for these residents.