Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a care plan addressing the need for supplemental oxygen use for one resident with significant respiratory diagnoses. The resident had acute respiratory failure with hypoxia, COPD, and an anxiety disorder, and a physician's order directed the use of oxygen via nasal cannula or non-rebreather at two to three liters per minute as needed to maintain oxygen saturation above 92%. Despite these orders and the resident's ongoing use of oxygen therapy, clinical record reviews and observations revealed that there was no care plan in place to address the resident's respiratory conditions and oxygen utilization at the time of review. The deficiency was identified through clinical record reviews, direct observation of the resident using oxygen, and interviews with facility staff. The facility's own policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and interventions based on thorough assessment. However, the care plan for this resident was not developed until several days after the deficiency was noted, and staff interviews confirmed that a care plan should have been in place to address the resident's respiratory needs and oxygen use.