Failure to Develop Comprehensive Care Plan for Continuous Oxygen Use
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing the continuous use of oxygen for one resident. The resident was admitted and later readmitted with diagnoses including pneumonia, urinary tract infection, and acute respiratory failure with hypoxia. Medical records, including the Minimum Data Set and physician's orders, indicated the resident required continuous oxygen via nasal cannula at 2-3 liters per minute. Progress notes and direct observation confirmed the resident was consistently receiving oxygen as ordered. Despite the ongoing administration of oxygen, a review of the resident's care plans revealed that no comprehensive care plan was developed to address the continuous oxygen therapy. Interviews with nursing staff and the Director of Nursing confirmed the absence of such a care plan, even though facility policy required the development and implementation of person-centered care plans to meet residents' medical and physical needs.