Failure to Develop Care Plan for COPD Diagnosis
Penalty
Summary
The facility failed to develop and implement a care plan addressing the needs of a resident diagnosed with chronic obstructive pulmonary disease (COPD), despite the resident's complex medical history and ongoing respiratory needs. The resident, who had severe cognitive impairment and required substantial to maximum assistance with activities of daily living, was admitted with diagnoses including COPD with acute exacerbation, Alzheimer's disease, and acute respiratory failure with hypoxia. The resident was observed receiving supplemental oxygen and nebulizer treatments, and medical records documented ongoing respiratory symptoms and interventions, including oxygen therapy and medication adjustments. However, a review of the care plan report and the resident's hard chart revealed no problem statement or interventions related to COPD or supplemental oxygen use. Interviews with facility staff, including the MDS Coordinator and Director of Nursing, confirmed that a care plan for COPD should have been developed but was overlooked. The facility's policy required the interdisciplinary team to create a comprehensive, person-centered care plan with measurable objectives and timeframes for all identified needs, but this was not followed for the resident's primary respiratory diagnosis. Documentation showed that care planning discussions and changes were communicated with the resident's family, but these were not reflected in the formal care plan documentation.