Failure to Develop and Implement Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for oxygen therapy for a resident with chronic respiratory failure and obstructive sleep apnea. The resident was admitted with these diagnoses and had a physician's order for oxygen therapy at two liters per minute as needed. Observations on two separate occasions confirmed that the resident was receiving oxygen therapy via nasal cannula at the bedside. Despite this, a review of the resident's care plans revealed that there was no current care plan addressing oxygen administration. During interviews, the DON confirmed that a care plan for oxygen therapy should have been in place, including interventions such as keeping the resident's head elevated and monitoring oxygen levels. The DON acknowledged that the absence of a care plan was an oversight and that the MDS should have prompted staff to create one. This lack of a care plan meant that necessary interventions for the resident's oxygen therapy were not formally documented or implemented.