Failure to Include Oxygen Administration Parameters in Care Plan
Penalty
Summary
A deficiency was identified when a resident receiving continuous oxygen therapy did not have a comprehensive care plan that included specific oxygen administration parameters. The resident, who had a history of lung damage due to a past COVID-19 infection, was observed receiving oxygen via nasal cannula at a rate of six liters per minute, despite the physician's order specifying administration at two liters per minute with titration to maintain an oxygen saturation of 92% or greater. The resident was unaware of the oxygen rate being administered, as this was managed by the nursing staff. During interviews and medical record reviews, it was found that nursing staff, including an LVN and an RN, were uncertain about the maximum oxygen rate permissible via nasal cannula, with the LVN stating the order did not specify a maximum rate and the RN referencing facility policy that set a maximum of five liters per minute for nasal cannula use. Documentation in the resident's medical record did not specify the rate of oxygen being administered, and the care plan addressing oxygen therapy failed to include the necessary parameters for titration or maximum allowable rates. The ADON confirmed that the care plan should have included the oxygen administration parameters and that staff should have attempted to administer the lowest amount of oxygen required to maintain the resident's oxygen saturation at or above 92%, as per the physician's order. The lack of clear documentation and guidance in the care plan led to the resident receiving a higher rate of oxygen than specified, without appropriate titration or monitoring as required.
Plan Of Correction
4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The DON or designee will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 The DON or designee will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 104 was affected by this deficient practice. Immediately, Unit manager removed resident 104's nebulizer machine at bedside and updated care plan. On 8/6/2025-8/8/2025, DON in-serviced all licensed nurses about facility policy and procedure for timing and revision of resident's plan of care, in particular updating plan of care when an order was discontinued and making sure any equipment related to the plan of care was removed from resident's bedside. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents were potentially affected by this deficient practice. DON and Unit managers audited 10 random residents to make sure the plan of care is up-to-date and found no other issue. DON or designee will provide ongoing in-services to all licensed nurses about timing and revision of care plan per facility policy and procedure. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: DON will oversee the process of revising and updating the plan of care. Unit Manager or designee will review 24-hours and 72-hours audits to make sure all discontinued treatment will reflect on the plan of care. Medical records will audit all new and discontinued orders to make sure the plan of care was updated and will report during clinical meetings for any non-compliance (M-F) x 3 months.