Failure to Develop and Implement Comprehensive Care Plans for Hospice and Oxygen Use
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents. One resident, with diagnoses including COPD, dementia, hypertension, and seizures, was receiving hospice care as indicated by physician orders and MDS documentation, but there was no documented focus, goal, or interventions for hospice care in the resident's care plan. Another resident, diagnosed with secondary malignant neoplasm of bone, hypertension, dementia, and chronic pain, was observed receiving oxygen therapy via nasal cannula, but there was no physician order or care plan documentation for oxygen use, nor was there an oxygen in use sign posted in the room. Interviews with the MDS Coordinator and DON revealed a lack of awareness regarding how these omissions occurred, despite their stated responsibilities for care plan development and review. The facility's policy requires comprehensive care plans to be developed and implemented for each resident, including measurable objectives and timeframes, but this was not followed for the residents in question. Record reviews and direct observations confirmed that the required care planning for hospice services and oxygen use was not completed or documented as required.