Failure to Include Oxygen Therapy and Related Diagnoses in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a complete care plan was developed and implemented for a resident with chronic obstructive pulmonary disease, chronic systolic (congestive) heart failure, and asthma. The resident was observed receiving oxygen via nasal cannula, with the oxygen concentrator set at varying rates, and staff reported the resident often removed the cannula at night, requiring adjustments to oxygen delivery. Despite a physician's order for continuous oxygen at 2 liters per minute, the resident's care plan did not include documentation related to oxygen use or the associated diagnoses. Interviews and record reviews confirmed that the care plan lacked problems, goals, or interventions addressing the resident's need for oxygen therapy and monitoring for respiratory symptoms. The DON acknowledged that the care plan should have included these elements and confirmed their absence prior to a later update. This omission meant that staff may not have been fully aware of the resident's needs regarding oxygen administration and monitoring.