Failure to Develop and Implement Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident with multiple respiratory diagnoses, including Alzheimer's Disease, COPD, respiratory failure, asthma, and heart failure. Despite the resident's Minimum Data Set (MDS) assessment indicating severe cognitive impairment and the need for oxygen therapy, the care plan did not include any problems or interventions related to respiratory conditions or oxygen use. Physician's orders documented the need for oxygen administration at 2 L/min via nasal cannula, weekly changes of oxygen tubing, weekly cleaning of the oxygen concentrator filter, and elevating the head of the bed for shortness of breath, but these were not reflected in the care plan. Observations confirmed that the resident was using oxygen as ordered, but interviews with the resident revealed uncertainty about the frequency of oxygen use. Staff interviews, including with the MDS RN and DON, confirmed that the care plan was missing required information regarding oxygen use and respiratory diagnoses. The MDS RN acknowledged that the omission was an oversight and emphasized the importance of accurate MDS coding for care planning. The DON also confirmed that the care plan should direct all aspects of resident care and must be accurate.