Failure to Develop and Implement Comprehensive Care Plans for Oxygen Therapy and PTSD
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies identified during the survey. For one resident with chronic respiratory failure, morbid obesity, and obstructive sleep apnea, the clinical record and physician's orders indicated the use of oxygen therapy. Despite documentation of oxygen use in the resident's records and direct observation of oxygen administration, there was no corresponding care plan addressing oxygen usage. The MDS coordinator confirmed that oxygen usage should have been included in the care plan, and facility policy requires that care plans describe all services necessary to meet residents' needs. For another resident diagnosed with post-traumatic stress disorder (PTSD) and other significant medical and psychiatric conditions, the care plan failed to identify potential triggers for PTSD. Although the resident's diagnosis and risk for PTSD-related symptoms were documented, the care plan did not include specific interventions or triggers. Interviews with administrative staff and the administrator revealed that the interdisciplinary team did not address or discuss the resident's PTSD during care plan meetings, and staff acknowledged the lack of appropriate assessment and intervention planning for trauma-informed care. Facility policies reviewed by the surveyor emphasized the need for comprehensive, person-centered care plans developed by the interdisciplinary team, incorporating risk factors and targeted interventions based on thorough assessments. The deficiencies were discussed with facility leadership, and no additional information was provided prior to the survey team's exit.