Failure to Develop and Implement Person-Centered Oxygen Therapy Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for residents receiving oxygen therapy, as required by their own policy. For one resident with diagnoses including COPD and acute respiratory failure with hypoxia, the care plan did not include any interventions for the use of oxygen, despite a physician's order for continuous oxygen at 2 liters per minute (LPM) via nasal cannula. Observations showed this resident was receiving oxygen at a higher flow rate of 3.5 LPM. For two other residents with similar respiratory diagnoses and physician orders for oxygen at 2 LPM, care plans did include interventions for oxygen use, but staff did not follow these interventions, as both residents were observed receiving oxygen at 3.5 LPM instead of the ordered rate. Staff interviews confirmed that the care plan interventions were not addressed or followed for these residents, and the MDS Coordinator acknowledged that the care plan serves as a blueprint for nursing care. The failure to develop and implement appropriate, individualized care plans for oxygen therapy was identified through review of medical records, care plans, physician orders, and direct observation of care.