Failure to Develop and Implement Oxygen Therapy Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing oxygen therapy for two residents with significant respiratory diagnoses. Both residents had documented needs for oxygen therapy, as evidenced by their medical diagnoses, MDS assessments, and nursing progress notes indicating use of oxygen for conditions such as chronic respiratory failure, COPD, and hypoxia. Despite these needs, neither resident had a care plan that included oxygen therapy, and there were no physician orders for oxygen administration in their records. Observations confirmed that both residents were receiving oxygen at specified flow rates, and staff interviews verified the absence of corresponding care plans and physician orders. The Director of Nursing (DON) acknowledged that oxygen therapy should have been included in the care plans and confirmed the omission after reviewing the records. The DON also stated that responsibility for completing care plans was shared among all administrative nurses of the interdisciplinary team, but could not explain why the care plans for oxygen therapy were missing. Facility policy requires that comprehensive care plans be developed for each resident, including measurable objectives and timeframes to meet all identified needs from the resident's assessment.