Failure to Include Oxygen Use in Resident's Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting the resident's oxygen use as a focus area. Record review showed that the resident, a cognitively intact female with diagnoses including sepsis and heart failure, required substantial to maximal assistance with activities of daily living and used oxygen as a special treatment. Despite this, her comprehensive care plan did not include any interventions or objectives related to oxygen use. Interviews with facility staff confirmed that there was no care plan for oxygen use in either of the electronic medical record systems until it was added after the deficiency was identified. The MDS Coordinator acknowledged the omission, and the DON emphasized the importance of comprehensive care plans and MDS assessments in ensuring correct and safe care. Facility policy requires the interdisciplinary team to develop a comprehensive care plan within seven days of completing the assessment, but this was not followed in this case.