Failure to Develop Baseline Care Plan for Oxygen Therapy and Non-Compliance
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission to address a resident’s oxygen therapy needs and known non-compliance with oxygen use. The resident was admitted with diagnoses including pneumonia and acute respiratory failure with hypoxia. Discharge instructions from the sending provider specified oxygen therapy at 2 L/min via nasal cannula on a continuous basis, with monitoring of oxygen saturation and use of supplemental oxygen as needed to maintain a goal saturation of 92%. The admission/readmission comprehensive nursing assessment documented an oxygen saturation of 98% via nasal cannula, confirming that the resident was receiving oxygen on admission. Despite this, a formal physician order for oxygen was not entered until several days after admission, and the MAR did not show oxygen therapy initiated until that later date. The resident’s care plan, initiated after the oxygen order, identified altered respiratory status related to respiratory failure with hypoxia but did not include any interventions addressing oxygen use, the resident’s non-compliance with wearing oxygen, or any monitoring plan for oxygen saturation. During interviews, the Unit Manager stated that the resident was on oxygen and was non-compliant with its use, and indicated that a care plan would be in place for such non-compliance. The DON acknowledged that there was no care plan for oxygen or for non-compliance with oxygen, despite facility policy requiring a comprehensive, person-centered care plan to meet residents’ needs.
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