Failure to Include Oxygen and Anticoagulant Therapy in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for one resident, as required by its own Care Planning Policy. Despite the resident being observed with a nasal cannula in place on multiple occasions and having documented diagnoses of Chronic Obstructive Pulmonary Disease and Atrial Fibrillation, the resident's care plan did not include interventions or monitoring related to oxygen therapy or anticoagulant medication use. The resident's physician orders specified oxygen therapy to maintain O2 saturation above 90% and the use of Apixaban as a blood thinner, both of which were also reflected in the Minimum Data Set. However, a review of the current care plan revealed that it lacked any mention of the resident's oxygen use, monitoring requirements, or anticoagulant therapy and associated monitoring. The facility administrator confirmed that care plans are expected to be updated with any change in condition and acknowledged that the resident's care plan did not include these critical elements.