Failure to Develop and Implement Oxygen Care Plan
Penalty
Summary
Facility staff failed to develop and implement a care plan (CP) for a resident who had a physician's order for oxygen therapy via nasal cannula at 2 liters per minute. The resident, who was admitted with multiple diagnoses including Parkinson's, COPD, diabetes mellitus, and atrial flutter, was assessed as moderately cognitively impaired with a BIMS score of 5/15. Despite the presence of an active order for oxygen therapy, a review of the resident's care plan did not show any evidence of an oxygen care plan being initiated or documented. Interviews with facility staff confirmed that a care plan should have been in place for any resident receiving oxygen, as it is considered a medication and requires monitoring of respiratory status. Both the RN and the DON acknowledged the absence of an oxygen care plan for this resident. Facility policies reviewed also required that oxygen administration be consistent with professional standards and incorporated into comprehensive, person-centered care plans, but this was not followed in the resident's case.