Failure to Develop Comprehensive Care Plans for Residents Requiring Respiratory Care
Penalty
Summary
The facility failed to develop and implement comprehensive care plans (CCPs) that addressed the respiratory care and oxygen needs for two residents who required such services. Facility policy required that CCPs include specific interventions for oxygen therapy, such as the type of delivery system, administration schedule, flow rates, monitoring requirements, and potential complications. However, for both residents sampled, the CCPs did not contain any information related to their respiratory care or oxygen use, despite physician orders and assessments indicating the need for continuous or as-needed oxygen therapy. One resident was observed using an oxygen concentrator set at 3 liters per minute and had diagnoses of chronic respiratory failure with hypoxia and acute pulmonary edema. The resident's Minimum Data Set (MDS) and physician orders documented the need for continuous oxygen and specific parameters for administration, yet the CCP lacked any mention of these needs. Interviews with the MDS coordinator and Director of Nursing confirmed that the care plan did not address the resident's respiratory care or oxygen use, and that this was not in accordance with facility policy. Another resident had physician orders for nebulizer treatments and as-needed oxygen to maintain saturation above 90%, with the MDS also indicating continuous oxygen use. Observations confirmed the presence of oxygen and nebulizer equipment in the resident's room, but the CCP did not reflect any respiratory care needs. Additionally, an LPN was unaware of the current nebulizer orders, and the MDS coordinator confirmed the omission of respiratory care needs from the care plan.