Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan for a resident who required oxygen therapy. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), schizoaffective disorder, and interstitial lung disease, was admitted and readmitted to the facility with orders for oxygen administration at two liters per minute via nasal cannula to maintain oxygen saturation at or above 92%. Despite these medical needs and physician orders, a review of the resident's electronic record revealed that no care plan addressing oxygen administration was created. Interviews with facility staff, including an LVN and the DON, confirmed that a care plan for oxygen therapy should have been developed to provide guidance on monitoring, interventions, and the specifics of oxygen delivery. The facility's policies and procedures also required comprehensive, person-centered care planning based on physician orders and resident needs. The absence of a care plan for oxygen therapy meant there was no documented guidance for staff on how to manage the resident's oxygen needs.