Failure to Care Plan Resident’s Repeated Removal of Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who required continuous oxygen therapy received care consistent with professional standards of practice and a comprehensive, person-centered care plan. The resident was an older female with diagnoses including unspecified dementia without behavioral disturbance, type 2 diabetes mellitus, combined systolic and diastolic congestive heart failure, chronic pulmonary edema, and paroxysmal atrial fibrillation. A 5‑day MDS showed she was cognitively intact with a BIMS score of 14. Physician orders directed continuous oxygen at 2 L via nasal cannula, and the care plan included a focus on oxygen therapy related to CHF with an intervention to administer oxygen per MD orders. Despite this, the care plan contained no language addressing the resident’s behavior of removing her nasal cannula or non‑compliance with oxygen therapy. Multiple staff interviews confirmed that the resident frequently removed her oxygen. An LVN stated the resident would occasionally remove her oxygen and that nurses and the respiratory therapist would replace it when notified by CNAs or during rounds. A CNA reported that the resident removed her oxygen and that staff repeatedly put it back on, only for the resident to remove it again. Another LVN described the resident as constantly removing her oxygen and needing frequent correction. The respiratory therapist reported that the resident was always taking off her oxygen and that staff were constantly checking to ensure it was on, with this behavior being communicated in report. The MDS nurse acknowledged that staff had reported the resident sometimes removed her oxygen and needed reminders, and he stated that this behavior should have been on the care plan but was not, explaining that he relied on behavior reports, particularly after the resident’s readmission, to update care plans. The DON also stated that the resident had continuous oxygen orders and had previously been known to constantly remove her oxygen, and that staff were aware and had to monitor her. Both the MDS nurse and the DON stated that the behavior of removing oxygen should have been on the care plan, but it was not included, and facility policies on oxygen administration and care plans did not contain specific language about documenting such behaviors on the care plan.
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