Failure to Develop and Document Comprehensive Care Plan for Resident with Respiratory Conditions
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with significant respiratory diagnoses, including respiratory failure, asthma, and COPD. The resident was found in possession of a vaping device, but this was not addressed in the care plan. Interviews revealed that staff members, including a Quality Assurance Nurse and a Certified Nursing Assistant, were aware of the resident's possession of the vaping device, but there was no documentation or communication to the assigned nurse, and no care plan was initiated to address the risk associated with the vaping device. Additionally, the existing care plan for oxygen use was incomplete, lacking specific and measurable goals and interventions. Record reviews and staff interviews confirmed that the care plans were not individualized or specific to the resident's needs, particularly regarding the risk posed by the vaping device and the management of the resident's respiratory conditions. Facility policies required comprehensive, person-centered care plans and complete, accurate documentation of services and changes in resident condition, but these were not followed. As a result, the resident's needs related to respiratory care and safety were not fully addressed.