Failure to Complete Comprehensive Care Plans for Pain and Oxygen Use
Penalty
Summary
The facility failed to complete comprehensive care plans for two residents, resulting in unaddressed care needs. One resident with a diagnosis of trigeminal neuralgia had a care plan that did not include staff instructions for non-pharmacological pain interventions, despite receiving both scheduled and PRN pain medications and reporting pain levels ranging from zero to nine on a one to ten scale. The resident's medical record included physician orders for pain management medications, and staff observed the resident experiencing pain, as evidenced by facial grimacing. The facility's pain management policy required individualized interventions for residents with pain to be documented in the care plan, but this was not done for this resident. Another resident with a diagnosis of respiratory failure and receiving oxygen therapy did not have staff instructions regarding oxygen use included in the care plan. The resident's medical record documented ongoing oxygen use per nasal cannula, as ordered by the physician, and staff observed the resident using oxygen during multiple visits. The facility's policy required the development of a care plan to address each resident's needs, but the omission of oxygen use instructions in the care plan represented a failure to communicate essential care requirements.