Failure to Develop Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
Staff failed to develop a comprehensive care plan for a resident who was admitted with multiple respiratory diagnoses, including Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, pleural effusion, acute and chronic respiratory failure with hypoxia, and an anxiety disorder. The care plan in place noted the use of oxygen therapy related to COPD and respiratory therapy, and included an intervention to monitor for signs and symptoms of respiratory distress and report to the provider as needed. However, the care plan lacked person-centered interventions, did not specify baseline vital signs, and did not describe the oxygen therapy in terms of frequency or indication for use. Observation confirmed that the resident was using an oxygen concentrator with a nasal cannula in her room. Review of the electronic health record revealed there was no physician order for the use of oxygen. Staff interviews confirmed the resident was receiving oxygen therapy and that the care plan did not meet expectations for person-centered interventions related to oxygen therapy.