Failure to Care Plan Oxygen Therapy for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who required oxygen therapy. Record review showed that the resident, an older adult female with diagnoses including abnormal lung findings, neuromuscular bladder dysfunction, stroke, and diabetes, had a physician's order for oxygen at 2-3 liters per minute via nasal cannula every shift for hypoxia. The resident's quarterly MDS assessment indicated she used oxygen and had moderately impaired cognition. However, her care plan, as of the most recent revision, did not include any information or interventions related to oxygen therapy. Observations confirmed that the resident had oxygen equipment in her room and an oxygen sign outside her door, but she was not observed using oxygen during multiple checks. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, revealed that the omission of an oxygen care plan was not recognized until brought to their attention. The facility's policy requires a comprehensive care plan to address all identified needs, including measurable objectives and timeframes, but this was not followed for the resident's oxygen therapy.