Omission of Supplemental Oxygen in Baseline Care Plan
Penalty
Summary
The facility failed to include the use of supplemental oxygen on the baseline care plan for a resident who was admitted with diagnoses including atherosclerotic heart disease and chronic idiopathic venous hypertension with ulcers to both lower legs. Although the hospital discharge summary did not indicate the use of oxygen, nursing documentation showed that the resident was receiving oxygen by nasal cannula shortly after admission. The baseline care plan created for the resident addressed pressure ulcers, wound care, pain and anti-anxiety medications, and the use of a PICC line for IV antibiotics, but did not mention oxygen therapy as a focus area. Interviews with staff revealed that the MDS Coordinator was unaware the resident had been receiving oxygen since admission, and the omission was attributed to the absence of a physician order for oxygen in the electronic medical record at the time of admission. The MDS Nurse later assessed the resident for oxygen use but did not update the baseline care plan accordingly. The administrator confirmed that the individualized, person-centered baseline care plan should be accurate and updated as needed, and acknowledged that the omission occurred because the hospital discharge orders did not include oxygen therapy.