Failure to Develop Baseline Care Plan for Oxygen and Antibiotic Use
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, specifically neglecting to address the resident's use of oxygen therapy and the administration of ciprofloxacin, an antibiotic. Observation revealed the resident was receiving oxygen at 3 liters per minute via nasal cannula following a recent hospitalization. The resident's admission record documented diagnoses including a lumbar vertebra fracture and bronchiectasis, and the order summary confirmed an active prescription for ciprofloxacin. Interviews with facility staff, including the Infection Preventionist, LVN, and Director of Nursing, confirmed that care plans should have been created for both oxygen use and antibiotic therapy. The facility's policies and job descriptions also required the development of baseline care plans within 48 hours of admission to address immediate health and safety needs. However, no such care plan was found for the resident's oxygen or antibiotic use, resulting in a lack of documented interventions and instructions for staff regarding these treatments.