Failure to Develop and Implement Person-Centered Care Plans for Oxygen Use and Fall Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for identified resident needs. For one resident admitted with diagnoses including orthopedic aftercare, unspecified COPD, and acute and chronic respiratory failure with hypoxia, the physician ordered continuous oxygen at two liters per minute via nasal cannula every shift. The resident’s H&P documented that the resident did not have capacity to understand and make decisions, while the MDS indicated intact cognitive skills for daily decisions and a need for supervision with hygiene, toileting, and showering. Despite these findings and the continuous oxygen order, staff interviews and record review confirmed there was no care plan addressing the resident’s noncompliance or refusal related to oxygen use. During an observation at the bedside, the resident was found asleep with the oxygen concentrator running at five liters per minute, but the nasal cannula was not connected and was hanging on a portable emergency light on the rolling table. The RN present verified that oxygen was running at five liters per minute and that the cannula was not in place. A CNA stated that if the cannula was not connected, the resident had removed it. The LVN and ADON both confirmed on review that there was no care plan developed for the resident’s refusal or removal of the oxygen cannula. The DON stated that without a care plan for the resident’s removal of the oxygen cannula, the facility would not be able to provide care and address the resident’s refusal, and that the resident could have hypoxia for not using oxygen. For a second resident admitted with left shoulder primary osteoarthritis, morbid obesity, and right knee pain, the H&P documented fluctuating capacity to understand and make decisions. The resident’s care plan for fall risk, initiated at admission, included an intervention to keep the bed in a low position with brakes locked. The MDS showed intact cognitive skills for daily decisions and a need for moderate assistance with toileting and lower body dressing, and a Fall Risk Observation/Assessment identified the resident as high risk for falls. However, during observation, the resident was found asleep with the bed in a high position. The ADON confirmed there was no care plan addressing the resident’s bed being kept in a high position, even though the resident was at high risk for falls and reportedly preferred the bed high. A CNA stated it was the first time she observed the bed high and acknowledged the resident could fall off if left too high, and an LVN stated he had just learned of the resident’s preference for a high bed and that a care plan should have been developed for this preference to prevent falls. The DON confirmed that the resident was high risk for falls, had no care plan for a high bed position, and that the resident put the bed up high and this should have been care planned as a resident preference.
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