Failure to Develop Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who required oxygen therapy. According to the facility's own Care Plan Policy, each resident should have a care plan that includes measurable objectives and timetables to address their medical, nursing, and psychosocial needs. Review of the clinical record for a resident admitted with diagnoses of respiratory failure, chronic obstructive pulmonary disease, and hypertension revealed a physician's order for oxygen therapy as needed. Documentation showed that the resident used oxygen on 31 days during the review period. Despite the resident's ongoing need for oxygen therapy, there was no evidence in the care plan that respiratory care or the use of oxygen was addressed. This omission was confirmed by the Director of Nursing, who acknowledged that a respiratory care plan should have been developed for the resident. The deficiency was cited under relevant state codes for responsibility of licensee, management, and nursing services.