Failure to Develop and Implement Comprehensive Care Plans for Insulin and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as identified through observation, interview, and record review. For one resident with an order for Insulin Glargine administered via a sliding scale, there was no corresponding care plan addressing the use of insulin. This was confirmed during a review of the resident's electronic health record and through interviews with the Director of Nursing, who acknowledged the absence of a care plan for insulin administration despite the physician's order. Another resident, who was observed receiving oxygen therapy via nasal cannula, also lacked a care plan addressing respiratory care, including oxygen administration. Interviews with an LPN and the Director of Nursing confirmed that the resident's care plan did not include interventions or evaluations related to respiratory care, despite physician orders for oxygen and facility policy requiring such interventions to be documented in the care plan. The resident's diagnoses included vascular dementia and an order for oxygen therapy with specific parameters, but these were not reflected in the care plan.