Failure to Include Oxygen Therapy and Side Rail Use in Resident Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans as required by its Comprehensive Person-Centered Care Planning policy, revised April 2025. The policy states that the IDT must develop and implement a comprehensive, person-centered, culturally competent, and trauma-informed care plan for each resident within seven days of completion of the MDS, including needs identified in the comprehensive assessment, specialized services from PASARR recommendations, and the resident’s goals, desired outcomes, and discharge preferences. Record review showed that a resident with multiple diagnoses, including acute posthemorrhagic anemia and COPD, had a physician’s order dated 12/19/25 for continuous oxygen at 2 LPM via nasal cannula every shift, but this oxygen use was not documented in the resident’s care plan. During an interview on 1/6/25 at 11:54 AM, the DON confirmed that the resident’s oxygen had not been care planned and acknowledged that it should have been. Another resident, admitted with multiple diagnoses including acute respiratory failure with hypercapnia, schizoaffective disorder, and AFib, was observed on 1/5/26 at 10:21 AM with bilateral upper side rails in use on the bed. Review of this resident’s care plan showed that the use of side rails was not documented. In an interview on 1/6/26 at 1:38 PM, the DON stated that the resident’s care plan did not document the use of side rails and confirmed that it should have. Based on observation, policy review, record review, and staff interview, surveyors determined the facility failed to develop and implement comprehensive resident-centered care plans for 2 of 17 residents reviewed, placing residents at risk of negative outcomes if services were not provided or were provided incorrectly due to lack of information in their care plans.
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