Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
A resident with a history of chronic combined systolic and diastolic congestive heart failure was admitted to the facility and was observed receiving oxygen therapy at 2 liters per minute via nasal cannula. During interviews and record reviews, it was confirmed by both nursing staff and the Director of Nursing that the resident was on oxygen therapy as needed for shortness of breath. However, it was found that no care plan had been developed to address the resident's oxygen use, despite the resident's ongoing need for this intervention. The lack of a care plan for oxygen therapy was acknowledged by both the licensed nurse and the Director of Nursing, who confirmed that the facility's policy and procedure required a comprehensive, measurable, and time-framed care plan for each resident. The absence of this care plan meant that appropriate goals and interventions for the resident's oxygen therapy were not documented or communicated to staff, contrary to facility policy and professional standards of practice.