Failure to Care Plan Oxygen Therapy for Resident
Penalty
Summary
The facility failed to develop and implement a person-centered care plan with measurable interventions for a resident who had physician orders for supplemental oxygen. Despite the resident having multiple diagnoses, including hemiplegia, Type 2 diabetes, hypothyroidism, and anxiety disorder, and being cognitively impaired as indicated by a BIMS score of 08, the care plan did not include a focus area or interventions related to oxygen therapy. Physician orders documented the need for continuous supplemental oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 90%, but this was not reflected in the resident's comprehensive care plan. Interviews with facility staff, including a CNA, LPN, MDS Coordinator, and DON, confirmed that oxygen therapy should have been included in the care plan. Staff were aware of the resident's oxygen use through nursing reports and physician orders, but the omission in the care plan was acknowledged by the MDS Coordinator and LPN, who were unable to locate any oxygen-related interventions in the care plan. Facility policies reviewed also indicated that care plans should address special needs such as oxygen administration, but this was not done for the resident in question.