Failure to Develop and Implement Individualized Care Plans for Oxygen Therapy and Hydration
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with specific and individualized interventions for two residents. For one resident with chronic respiratory failure, quadriplegia, and a tracheostomy, there was a discrepancy between the physician’s order for oxygen therapy and the interventions listed in the care plan and Kardex. The physician’s order specified oxygen at 10 liters per minute via nasal cannula or tracheostomy collar, but the care plan and Kardex indicated oxygen at only 2 liters per minute. Observation confirmed the resident was receiving oxygen at 10 liters per minute, but the care plan and Kardex had not been updated to reflect this, resulting in a lack of alignment between the physician’s order and the documented plan of care. For another resident with Parkinson’s disease, hemiplegia, and hemiparesis following a stroke, the care plan addressed several nutritional concerns and included general interventions for monitoring hydration. However, the care plan did not identify that the resident was fully dependent on staff for hydration or include individualized interventions to ensure the resident’s fluid needs were proactively assessed and met. The resident, who was cognitively intact but required total staff assistance with eating and drinking, reported that fluids were only offered at meals and that he had to use the call bell to request drinks at other times, often experiencing long delays due to his inability to provide himself with fluids. These deficiencies were confirmed through clinical record reviews, staff interviews, and resident interviews, which revealed that the care plans did not contain specific, individualized interventions to address the residents’ needs for oxygen therapy and hydration, as required by regulatory standards.