Failure to Initiate Care Plans for Pneumonia, Antibiotic, and Oxygen Therapy
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident diagnosed with pneumonia who was prescribed antibiotics and oxygen therapy. Record review showed that, despite physician orders for oxygen therapy and antibiotics, there were no corresponding care plans initiated for pneumonia, antibiotic use, or oxygen use. The resident in question had multiple diagnoses, including severe cognitive impairment, required assistance with activities of daily living, and used oxygen for shortness of breath. The facility's policy required that care plans be updated as residents' conditions changed, but this was not followed in this case. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans. The DON acknowledged weaknesses in the current care plan update process and noted ongoing efforts to improve it. The MDS Coordinator and nursing staff provided conflicting accounts of who was responsible for initiating and updating care plans following new orders. Ultimately, the care plans for pneumonia, antibiotic use, and oxygen therapy were not created or updated as required, resulting in noncompliance with regulatory requirements.