Failure to Develop Care Plans for Pain Management and Oxygen Use
Penalty
Summary
The facility failed to develop and implement care plans for pain management and oxygen use for one resident. Despite the facility's policy requiring a comprehensive, person-centered care plan for each resident, and revisions after each comprehensive and quarterly Minimum Data Set (MDS) assessment, no such care plans were created for this resident. The resident was admitted with diagnoses including chronic pain and syncope, and had a BIMS score indicating some memory and decision-making problems. Observations and interviews confirmed that the resident regularly used pain medication and oxygen, both of which were ordered by a physician. However, a review of the resident's care plans showed that neither pain management nor oxygen use was addressed. The Director of Nursing confirmed that these care plans were missing and acknowledged that they should have been developed.