Baseline Care Plan Omitted PRN Oxygen Order for Newly Admitted Resident
Penalty
Summary
The facility failed to create an accurate baseline care plan for a newly admitted resident by omitting an essential treatment order. Record review showed the resident was admitted with COPD, Alzheimer’s disease, dementia with agitation, major depressive disorder, and essential HTN. Physician orders dated 08/05/25 directed that the resident receive oxygen at 2 L/min via nasal cannula as needed for respiratory distress. However, review of the resident’s baseline care plan dated 08/04/25 revealed no indication that the resident utilized oxygen as needed, despite this active order. In an interview, the DON confirmed that the resident does use oxygen PRN and acknowledged that the baseline care plan did not reflect this need and that it should have been included. This discrepancy between the physician’s oxygen order and the baseline care plan content constituted the identified deficiency in accurately capturing the minimum healthcare information necessary to properly care for the resident immediately upon admission.
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