Failure to Implement and Document Required Fall and Respiratory Care Interventions
Penalty
Summary
The facility failed to develop and implement appropriate care plans for residents with specific needs, as evidenced by observations, interviews, and record reviews. For two residents with physician orders for bilateral floor mats to prevent falls, the care plans did not include interventions for floor mats, and the mats were not consistently in place as ordered. One resident was observed with only one floor mat in place when two were required, and staff interviews confirmed that the protocol was not consistently followed. Documentation showed a history of falls for these residents, and physician orders clearly specified the need for bilateral floor mats every shift, yet this intervention was omitted from the care plans and not reliably implemented in practice. Additionally, the facility failed to implement a respiratory care plan for a resident receiving oxygen therapy. The resident was observed receiving oxygen at a flow rate lower than the physician-ordered amount, and staff did not verify the oxygen flow rate during rounds. The resident's oxygen saturation was found to be critically low until the flow rate was corrected by staff. The care plan for this resident did include the need for oxygen therapy at the prescribed rate, but the intervention was not properly implemented, resulting in a deviation from the physician's order. These deficiencies were identified through direct observation, staff interviews, and review of medical records and care plans. The facility's own care planning policy requires individualized, interdisciplinary plans of care based on assessment findings and physician orders, but these requirements were not met for the residents in question, leading to lapses in the delivery of ordered interventions for fall prevention and respiratory care.