Failure to Update Care Plans for Hospice and Oxygen Therapy
Penalty
Summary
The facility failed to update the care plans for two residents, which did not accurately reflect their current medical needs. Resident R5, who was diagnosed with Alzheimer's disease, anemia, and chronic kidney disease, began receiving hospice services as indicated by a physician order dated 6/11/24. However, the care plan for Resident R5, reviewed on 1/9/25, did not include any goals or interventions related to the hospice care services that the resident was receiving. Similarly, Resident R195, diagnosed with chronic obstructive pulmonary disease, respiratory failure with hypoxia, and lung cancer, was ordered to receive continuous oxygen therapy as per a physician order dated 12/22/24. An observation on 1/8/25 confirmed that Resident R195 was using a nasal cannula for oxygen therapy, yet the care plan reviewed on the same day failed to include any goals or interventions related to the oxygen therapy. The Director of Nursing confirmed the oversight in updating the care plans for these residents.
Plan Of Correction
Resident 5's care plan will be reviewed by the DON/ designee and updated to reflect goals and interventions related to hospice services. Resident 195's care plan will be reviewed by the DON/ designee and updated to reflect goals and interventions related to oxygen therapy. Current residents who receive hospice services and/or require oxygen therapy have the potential to be affected. A comprehensive audit will be conducted by the DON/ designee to ensure hospice services and/or oxygen therapy is reflected in the care plan. Corrections will be made as needed. To prevent recurrence, the IDT will be educated on the Comprehensive Care Plan policy by the NHA/ designee. To maintain and monitor compliance, residents with new orders for hospice services or oxygen therapy will be audited by the DON/ designee to ensure care plans have been revised weekly x 4 weeks and monthly x 2 months. Results of the audits will be forwarded to the center QAPI committee for review and recommendations.