Failure to Include Oxygen Therapy and Aspiration Risk in Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan addressing all identified needs for two residents who were receiving oxygen therapy and for one resident with an increased risk of aspiration following a recent hospitalization for aspiration and respiratory failure. Observations confirmed that both residents were receiving oxygen via nasal cannula, and interviews with staff and residents revealed inconsistencies in the monitoring and supervision of meals, particularly for the resident with a history of aspiration. Documentation review showed that the Minimum Data Set (MDS) assessments for both residents indicated the use of oxygen therapy, and for one resident, documented swallowing difficulties and a history of aspiration. Despite these documented needs, the comprehensive care plans for both residents did not include problems, goals, or interventions related to oxygen therapy. Additionally, the care plan for the resident with a history of aspiration did not address the increased risk for aspiration or swallowing difficulties. Staff interviews confirmed that these care areas should have been included in the care plans, as identified by the MDS assessments.