Failure to Individualize Care Plans for Oxygen Therapy and Oral/Dental Needs
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for three residents regarding oxygen therapy and oral/dental status. For one resident with chronic obstructive pulmonary disease (COPD) and an order for supplemental oxygen, observations confirmed the resident was receiving oxygen therapy, but there was no corresponding care plan addressing this intervention. Both a Licensed Practical Nurse and the Director of Nursing Services acknowledged the absence of a care plan for oxygen use, despite the resident's ongoing therapy and provider orders. Another resident with cerebral palsy and multiple broken, discolored upper front teeth reported significant dental problems, but the care plan only included general oral care instructions and did not address the broken teeth or potential for oral pain. A third resident, dependent on artificial feeding and with a history of malnutrition and gastrointestinal hemorrhage, stated a need for lower dentures, but the care plan did not include any information or instructions regarding missing lower teeth. The Director of Nursing Services confirmed that care plans should have included details about broken or missing teeth.