Failure to Develop Individualized Care Plans for Vaccine Refusal and Oxygen Noncompliance
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents as required by its own policies and procedures. For one resident who had the capacity to make decisions, the medical record showed a refusal to receive the COVID-19 vaccine, but there was no care plan initiated to address this refusal. Both the Infection Preventionist and a Registered Nurse confirmed during interviews and record reviews that a care plan should have been created for the resident's vaccine refusal, but none was found in the medical record. For another resident, also with decision-making capacity, there was a physician's order for continuous oxygen therapy via nasal cannula to maintain oxygen saturation above 90% due to COPD. Observations and interviews revealed that the resident was not consistently using the oxygen as ordered and sometimes removed the nasal cannula. Staff members, including a CNA and an LVN, acknowledged the resident's noncompliance and stated that a care plan should have been initiated to address this issue, but no such care plan was documented. The Director of Nursing confirmed the absence of a care plan for the resident's noncompliance with oxygen therapy.