Failure to Develop and Implement Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-focused care plan for a resident who was receiving oxygen therapy. The resident, who had a diagnosis of unspecified atrial fibrillation and was cognitively intact, was observed using oxygen via nasal cannula at 2 liters per minute and reported needing oxygen at all times due to difficulty breathing. Despite a physician's order for oxygen as needed for shortness of breath, there was no active care plan addressing the resident's oxygen use. The care plan related to oxygen had been marked as resolved, even though the resident continued to require and use oxygen. Interviews with facility staff, including the MDS nurse and the DON, confirmed that there was no current care plan in place for the resident's oxygen therapy. The facility's own policies required that care plans be developed, regularly evaluated, and updated to reflect the resident's needs, including measurable goals and target dates. The absence of a care plan for oxygen use was acknowledged by staff and was not in accordance with facility policy or standard care planning procedures.