Failure to Care Plan Oxygen Use for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed all the needs of two residents, specifically regarding their use of oxygen. For one resident, documentation showed she was severely cognitively impaired and required extensive assistance with daily activities. Although she was observed using oxygen and reported needing it for two years, her care plan and physician orders did not reflect this intervention. The omission was confirmed through record review and direct observation. Another resident, who was moderately cognitively impaired and had diagnoses including apraxia, dyspnea, and dementia, was also observed using oxygen. However, her care plan did not include oxygen use, and physician orders for oxygen were only updated after surveyor intervention. Prior to this, the only related order was for changing oxygen tubing as needed for infection control, with no standing order for oxygen administration documented in her records. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans, particularly for acute changes such as new oxygen orders. The MDS nurse, ADON, and other staff acknowledged that care plans should have included oxygen use for these residents but cited gaps in communication and documentation as reasons for the oversight. Facility policy requires comprehensive care plans to be developed and updated to reflect residents' current needs, but this was not followed in these cases.