Failure to Develop Individualized Respiratory Care Plan
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan to address a resident's specific respiratory care needs. Despite multiple documented incidents in the medical record, including the resident pulling out their tracheostomy tube, placing the nasal cannula in their mouth, biting the cannula, and chewing on oxygen tubing, there was no evidence that these behaviors were incorporated into the resident's care plan. The facility's policy requires that care plans include measurable objectives and timetables to address identified problems and risk factors, but this was not followed for the resident in question. Medical records and interviews confirmed that the resident had a tracheostomy, used supplemental oxygen, and lacked capacity to make decisions. Several health status notes detailed repeated episodes of self-decannulation and manipulation of respiratory equipment, which were observed by staff and reported by a family member. Both the RN and DON verified that the care plan did not address these behaviors, and the DON acknowledged that a care plan should have been developed to ensure appropriate care for the resident.