Failure to Include Oxygen Therapy in Resident Care Plans
Penalty
Summary
The facility failed to ensure that the care plans for three residents receiving oxygen therapy included specific interventions and focus areas for oxygen use, as required by facility policy. For each resident, physician orders and clinical assessments documented the need for oxygen therapy, including prescribed flow rates and monitoring requirements. However, the corresponding Resident Care Plans (RCPs) did not address oxygen therapy, omitting necessary details such as the type of delivery system, administration instructions, equipment settings, and monitoring protocols. This omission was identified through review of clinical records, facility documentation, and direct observation of residents receiving oxygen. Specifically, one resident with acute respiratory failure and heart failure was admitted with an order for oxygen but had no care plan interventions for oxygen therapy. Another resident with acute respiratory failure had a physician's order for continuous oxygen, was observed receiving oxygen, but the care plan did not include oxygen therapy until after surveyor inquiry. A third resident with chronic obstructive pulmonary disease had an order for oxygen and was receiving it, but the care plan failed to address oxygen therapy until prompted by surveyors. Interviews with facility staff confirmed that oxygen use should have been included in the care plans, in accordance with facility policy.