F0655

D

Failure to Develop Baseline Oxygen Care Plan on Admission

Stockton, California Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The facility failed to develop and implement a baseline care plan that included the interventions and instructions needed to provide effective and person-centered oxygen therapy for a newly admitted resident. The resident was admitted with multiple diagnoses, including acute osteomyelitis, sepsis, cellulitis and abscess of the mouth, type 2 diabetes, essential hypertension, bilateral blindness, depression, sleep apnea, morbid obesity, and anxiety. Hospital inpatient discharge instructions directed that oxygen be started at 2 L/min for shortness of breath, chest pain, or oxygen saturation less than 90%, with immediate physician notification for specified respiratory changes and abnormal findings. The facility signed the hospital discharge orders as noted and carried out, and the physician’s orders dated shortly after admission included continuous oxygen at 2 L/min via nasal cannula every shift.

Despite these orders, review of the resident’s care plans showed that no oxygen care plan was developed. The DON confirmed during interview and concurrent record review that the resident was admitted with oxygen therapy and that the baseline care plan summary, which the facility used as the resident’s baseline care plan, did not include specific interventions and instructions for oxygen therapy. The DON acknowledged that a specific oxygen care plan was not developed for this resident. Review of the facility’s “Baseline Care Plan Summary” policy, revised in October 2025, indicated that the facility was required to develop and implement a baseline care plan within 48 hours of admission that includes the minimum healthcare information necessary to properly care for a resident, but this was not done for the resident’s oxygen needs.