Failure to Care Plan Oxygen Therapy and Incentive Spirometer Use
Penalty
Summary
Surveyors identified a deficiency in that the facility failed to develop a care plan addressing oxygen administration via nasal cannula and the use of an incentive spirometer for one resident. The resident was admitted on 8/29/25 with diagnoses including pneumonia and respiratory failure. On 9/2/25, a physician ordered continuous oxygen at 6 L/min via nasal cannula, and on 9/3/25, a physician ordered use of an incentive spirometer, encouraging the resident to use it as often as tolerated. On 9/15/25, an observation of the resident’s bedside table showed an incentive spirometer, and the resident stated he was using it. However, on 9/16/25, review of the resident’s care plan showed no evidence of a care plan addressing either the ordered oxygen therapy or the incentive spirometer use. During an interview, the quality manager confirmed that no care plan had been developed for these treatments, and these findings were later reviewed with facility leadership during the exit conference.
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