Failure to Individualize Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to update and individualize the care plan for a resident who was receiving respiratory care, specifically oxygen therapy. The resident, who had moderate cognitive impairment and required assistance with all activities of daily living, had multiple diagnoses including atrial fibrillation, heart failure, hypertension, cerebrovascular accident, depression, ADHD, and aortic aneurysm and dissection. The Minimum Data Set (MDS) indicated that the resident was receiving oxygen therapy. However, upon review, the care plan only noted the use of oxygen without specifying the reason for its use, the prescribed oxygen flow rate, or the route of administration. Interviews with facility staff, including an LPN clinical coordinator and the assistant director of nursing, confirmed that the care plan lacked resident-specific information regarding oxygen therapy. Both staff members acknowledged that the care plan should include detailed instructions so that staff are aware of when, how, and at what liter flow oxygen should be administered. The facility's care planning policy requires that care plans be comprehensive, individualized, and include measurable goals and specific interventions, but these requirements were not met in this case.