Failure to Develop Individualized Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan with measurable objectives, timeframes, and interventions to address a resident's oxygen needs. The resident in question was admitted with diagnoses including sepsis, acute respiratory failure, and immunodeficiency, and was determined to lack the capacity to make decisions. Physician orders specified oxygen administration via nasal cannula at 1 liter per minute, with titration to maintain oxygen saturation at or above 95% as needed. However, review of the resident's care plans revealed that no care plan addressing oxygen use had been developed, contrary to facility policy and professional standards. During observation, the resident was seen without the nasal cannula in place and was hyperventilating while moving around. A registered nurse had to adjust the nasal cannula to ensure proper oxygen delivery. Staff interviews confirmed that a care plan for oxygen use was missing and should have been in place to guide staff in providing appropriate care. Facility policies reviewed indicated that care plans should describe the services necessary to maintain the resident's highest practicable well-being and that oxygen administration should be consistent with the care plan and resident's needs.