Failure to Develop and Implement Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple complex medical diagnoses, including COPD, heart failure, and a cardiac pacemaker, who was receiving oxygen therapy. The resident's admission record and physician orders indicated the use of oxygen as needed via nasal cannula and permission for self-administration of medications. However, review of the resident's care plan revealed no focus or interventions related to oxygen administration or self-administration of medications, despite documented use of oxygen on multiple occasions. Observations showed the resident managing their own oxygen therapy, with the oxygen tubing found lying on the ground, and the resident reporting self-directed use of oxygen. Interviews with facility staff, including the MDS RN and DON, confirmed the absence of a care plan addressing these needs. Facility policy requires individualized, person-centered care plans to be developed and updated to reflect resident needs, but this was not done for the resident in question.