Failure to Develop and Implement Comprehensive Respiratory Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address all of a resident's respiratory needs. The resident, who had diagnoses including obstructive sleep apnea (OSA) and acute respiratory failure with hypercapnia, was admitted from the hospital with discharge instructions to continue weaning off supplemental oxygen and to use CPAP at night. Although a care plan was created shortly after admission, it did not initially address the resident's altered respiratory status or difficulty breathing related to COPD until several weeks later. The care plan also lacked individualized interventions for the resident's use of supplemental oxygen and did not include a protocol or designate staff responsible for oxygen weaning, despite a physician's order for oxygen weaning being present. Additionally, the care plan was not updated to include specific, resident-centered interventions for the use of the CPAP machine, such as mask type, humidification, cleaning schedules, supply provision, or staff responsibilities. Facility policies reviewed did not provide a protocol for oxygen weaning, and the DON was unable to explain the omissions in the care plan or provide further information before the survey concluded. These deficiencies were identified through record review and staff interviews, and the administrator was made aware of the concerns.