Failure to Develop Respiratory Care Plan for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing respiratory care for a resident admitted with pneumonia who had a physician's order for oxygen therapy. Although the resident was ordered to receive oxygen via nasal cannula at 2 liters per minute to maintain oxygen saturation above 92%, the quarterly MDS assessment did not indicate oxygen therapy, and the resident's care plan dated 2/27/25 did not include respiratory care. Record review showed that oxygen therapy was administered daily, and direct observation found the resident in bed with an oxygen concentrator in use, but the tubing was not on the resident, who was observed coughing. Staff interviews confirmed that the resident frequently removed her oxygen tubing and required monitoring to ensure proper oxygenation, and both the MDS nurse and DON acknowledged the absence of a respiratory care plan as an oversight.