Failure to Develop and Implement Comprehensive Care Plans for Oxygen Therapy and Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents with significant clinical needs. For one resident, who was admitted with chronic kidney disease and had a physician's order for continuous oxygen inhalation at 2 liters per minute via nasal cannula to maintain oxygen saturation above 95%, there was no care plan addressing the use of continuous oxygen. This omission was confirmed through observation, record review, and staff interviews, including with the infection preventionist and the director of nursing, both of whom acknowledged the absence of a care plan for oxygen therapy. For another resident with diagnoses including type 1 diabetes, Alzheimer's disease, and depression, there was a documented significant weight loss of 16.6 pounds (10.5%) over six months. Despite this, there was no care plan in place to address the resident's significant weight loss, as confirmed by review of dietary and weight management notes, as well as staff interviews. The lack of care planning for these clinical issues meant that the residents did not have documented, measurable objectives and interventions to address their needs, as required by facility policy.