Failure to Develop and Implement Comprehensive Care Plans for Oxygen Therapy and Contractures
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans for two residents. For one resident with COPD and respiratory failure, staff did not follow the physician's order for oxygen therapy, as observations showed the oxygen flow rate was set between two and three liters per minute, rather than the ordered two liters per minute via nasal cannula. The resident's care plan specified that oxygen therapy should be administered as ordered, but this was not consistently followed. Staff interviews confirmed that the care plan was not adhered to when the oxygen was not set according to the physician's order. For another resident, staff failed to develop a care plan addressing the resident's contractures, despite repeated observations of contracted hands and feet. No contracture-related devices were observed in use, and the comprehensive care plan did not include interventions to prevent worsening of contractures. Interviews with nursing staff and the MDS coordinator confirmed that the contractures were not addressed in the care plan, and the CNA was unaware of any required interventions for the contractures.