Failure to Include Respiratory Interventions in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple respiratory diagnoses, including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea (OSA). Despite the resident having active physician orders for continuous oxygen therapy and nightly use of a BiPAP (non-invasive ventilator), these interventions were not documented in the resident's care plan. The care plan only addressed risks related to falls and pain management, omitting the resident's respiratory needs and the required interventions for oxygen and BiPAP use. Record reviews showed that the resident had a history of respiratory failure, pneumonia, morbid obesity, and COPD, and was receiving both oxygen and non-invasive ventilation as ordered by her physician. The medication administration records confirmed that these treatments were being provided. However, the care plan did not reflect these critical interventions, nor did it include measurable objectives or timeframes related to the resident's respiratory care, as required by facility policy and regulatory standards. Interviews with facility staff revealed that the nurse responsible for care plans was unaware of the need to include the resident's respiratory diagnoses and interventions until reviewing the orders. The nurse acknowledged that the care plan should have been updated upon admission to include these needs. The Director of Nursing also confirmed that the resident's respiratory needs should have been documented in the care plan to inform the interdisciplinary team and ensure continuity of care.