Failure to Develop Comprehensive Care Plans for Oxygen Therapy and Opioid Use
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific clinical needs. For one resident with diagnoses including atrial fibrillation and congestive heart failure, who was dependent on staff for all activities of daily living and had severely impaired cognitive skills, there was a physician's order for continuous oxygen therapy due to acute respiratory failure with hypoxia. However, upon review, staff could not locate a care plan addressing the resident's oxygen therapy, and both the MDS Coordinator and DON confirmed that a care plan should have been in place. In a separate case, another resident with chronic pain syndrome and intact cognition was receiving hydromorphone for moderate to severe pain on a regular basis, as documented in the Medication Administration Record. Despite the consistent administration of this opioid medication, there was no care plan addressing the resident's use of hydromorphone, including monitoring for adverse reactions or effectiveness. The DON acknowledged that a care plan should have been developed for this medication regimen. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes for all identified needs.