Failure to Develop Baseline Care Plan for Resident's Respiratory Needs
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident who required respiratory care and continuous oxygen support. Upon review, the resident was admitted with acute respiratory failure, heart failure, pneumonia, and chronic obstructive pulmonary disease, and had physician orders for continuous oxygen via nasal cannula at 2 liters per minute. Observation showed the resident receiving oxygen and experiencing difficulty breathing while lying flat. However, the baseline care plan did not document the resident's need for oxygen or any respiratory problems. Interviews and record reviews confirmed that the baseline care plan omitted necessary respiratory goals and interventions, despite the resident's significant respiratory diagnoses and ongoing oxygen therapy. The Director of Nursing acknowledged that the care plan should have included these elements to address the resident's immediate health and safety needs as required by facility policy.