Failure to Include Oxygen Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions. Specifically, the care plan did not include a focus area or interventions for the resident's use of oxygen, despite physician orders for oxygen administration at 4 L/min via nasal cannula as needed for symptoms such as shortness of breath and respiratory distress. The care plan addressed other issues such as pneumonia, nebulizer treatments, and hospice services, but omitted the resident's oxygen therapy needs. Record reviews showed that the resident had diagnoses including bone cancer, shortness of breath, anal cancer, cognitive communication deficit, difficulty swallowing, and a pressure ulcer. Observations confirmed the resident was receiving oxygen via nasal cannula, and interviews with the MDS nurse revealed that active problems treated in the facility should be reflected in the MDS and care plan. However, the MDS assessments did not indicate oxygen use, and the care plan was not updated to address this need.