Failure to Include Oxygen Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting the resident's requirement for oxygen therapy. Despite documentation in the resident's medical records and MDS assessment indicating an active order for oxygen therapy at specific flow rates to maintain oxygen saturation, the care plan did not include any interventions or objectives related to oxygen use. Multiple observations confirmed the resident was receiving oxygen via nasal cannula at varying flow rates, and interviews with the resident and staff confirmed ongoing oxygen therapy due to the resident's cardiac and respiratory diagnoses. Interviews with facility staff, including the MDS nurse and DON, revealed that they were responsible for updating care plans but acknowledged the omission and the potential for negative outcomes if care plans are not kept current. The facility's own policy requires that care plans include measurable objectives and timeframes for all identified needs, yet the resident's need for oxygen therapy was not reflected in the care plan, despite being a current and ongoing intervention.