Failure to Develop Comprehensive Care Plans for Oxygen Therapy and Antipsychotic Use
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents regarding their specific clinical needs. For one resident with chronic obstructive pulmonary disease and polyneuropathy, a physician order was in place for oxygen therapy due to pneumonia, but the comprehensive care plan did not address the use of oxygen therapy. This omission was confirmed by the unit manager during an interview. For another resident with diagnoses of dementia, depression, and breast cancer, a physician order was present for the administration of Rexulti, an antipsychotic medication, to manage behaviors. However, the care plan did not include any information regarding the use of the antipsychotic medication or monitoring for potential adverse reactions. The Director of Nursing confirmed that no care plan had been developed for the antipsychotic use. These findings were based on observations, staff interviews, and review of clinical records and policies.