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F0656
D

Failure to Develop Care Plan for Oxygen Therapy

Columbia, Pennsylvania Survey Completed on 07-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that a resident was receiving oxygen therapy via nasal cannula on two separate occasions. Upon review of the resident's clinical record, it was found that there was no care plan in place addressing the use of oxygen for this resident. An interview with the Director of Nursing confirmed that the resident did not have a care plan for oxygen use. This lack of a comprehensive care plan for a resident receiving oxygen constituted a failure to meet regulatory requirements for developing and implementing person-centered care plans based on identified medical needs.

Plan Of Correction

F 0656 The care plan for R1 was updated to include oxygen therapy. Residents requiring oxygen therapy have had their care plans updated to reflect their current condition. Education will be completed by the DON/Designee with licensed nurses and interdisciplinary team to ensure care plans are updated timely with any changes. The DON/designee will audit 10 resident care plans per week for 4 weeks then monthly times 2 months to ensure that residents requiring oxygen therapy have the appropriate care planned. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.

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