Failure to Include Respiratory Treatments in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed all of the residents' needs, specifically omitting respiratory treatments for five residents reviewed. Despite medical diagnoses such as Alzheimer's disease, vascular dementia, metabolic encephalopathy, and acute respiratory conditions with hypoxia, the care plans for these residents did not include details about their required respiratory therapies, such as oxygen therapy, nebulizer treatments, or inhalation medications. This omission was identified through record reviews, observations, and interviews, which revealed that while physician orders for respiratory treatments existed and residents were receiving these treatments, the care plans did not reflect these interventions. For example, one resident with Alzheimer's disease and acute respiratory issues had active orders for oxygen therapy and nebulizer treatments, but her care plan only addressed her ADL self-care deficit and did not mention respiratory care. Another resident with vascular dementia and acute respiratory needs had a care plan that addressed cognitive impairment but not the use of respiratory treatments, despite having orders for oxygen and nebulizer use. Similar deficiencies were found for other residents with severe cognitive impairment and complex respiratory needs, where care plans failed to document the specific respiratory treatments being provided, even though these treatments were observed or confirmed through interviews. Interviews with staff, including the DON and ADM, confirmed that care plans are expected to reflect all medical orders and treatments, and that it is the responsibility of nursing leadership to ensure care plans are updated to match current care and treatments. The facility's own policy requires the interdisciplinary team to develop comprehensive, person-centered care plans with measurable objectives and timeframes to meet all identified needs, but this was not followed for the residents reviewed, resulting in incomplete documentation of their respiratory care.