Failure to Update Care Plans After Resident Fall and Discontinuation of Oxygen Therapy
Penalty
Summary
The facility failed to review and update care plans for two residents following significant changes in their conditions. For one resident with a history of muscle weakness, abnormal posture, and a lumbar fracture, the care plan for fall risk was not revised after the resident experienced a fall while attempting to reach for a document, which resulted in hospitalization due to low oxygen saturation. Although new physician orders were issued to place the bed in a low position with bilateral landing pads and to monitor their placement, these interventions were not incorporated into the resident's care plan. Both the MDS Coordinator and the Director of Nursing confirmed that the care plan was not reviewed or updated after the fall, despite facility policy requiring such updates following a change in condition or hospital readmission. Another resident with chronic obstructive pulmonary disease, major depressive disorder, and respiratory failure had a care plan that was not updated after the discontinuation of continuous oxygen therapy. The resident's care plan continued to list oxygen administration as an intervention even after the physician order for oxygen was discontinued following a hospitalization. Observations revealed that the resident was still using oxygen equipment in the room, and staff were unaware that the order had been discontinued. The Director of Nursing confirmed that the care plan had not been revised to reflect the change in physician orders, and the resident was not informed that oxygen was no longer required. Facility policies reviewed indicated that care plans should be updated to reflect new interventions after a fall or a significant change in a resident's condition, including changes in physician orders. The failure to update care plans in both cases was acknowledged by facility staff and was not in accordance with the facility's own policies and procedures.