Failure to Care Plan for Oxygen Use and Floor Mat
Penalty
Summary
The facility failed to develop and implement an accurate, comprehensive care plan for a resident when staff did not include interventions for the use of supplemental oxygen and a floor mat. The resident was admitted on an identified date, and review of the care plan dated shortly after admission showed no care plan addressing the resident’s use of supplemental oxygen or the presence of a floor mat. Medical orders showed that the resident had an order, dated several days after admission, for supplemental oxygen via nasal cannula, but there was no corresponding care plan with interventions for this treatment. Surveyor observations and staff interviews confirmed the omission. During a random observation of the resident’s room, the resident was seen lying in bed wearing a nasal cannula connected to an oxygen concentrator, and a floor mat was present on the floor next to the right side of the bed. The ADON confirmed that the resident was using oxygen and had a floor mat in place. The DON also confirmed the resident’s use of oxygen and a floor mat and acknowledged that both should have been included in a care plan with interventions prior to their use, but were not.
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