Failure to Revise Care Plan to Include Oxygen Use
Penalty
Summary
The facility failed to review and revise a comprehensive, person-centered care plan for a resident, as required by policy and regulatory standards. Specifically, the care plan did not include documentation of the resident's oxygen usage, despite a physician's order allowing oxygen up to 5 liters as needed. The omission was identified through record review, which showed that the ongoing care plan did not address this aspect of the resident's care, even though the resident had significant medical diagnoses including cerebral infarction, atherosclerotic heart disease, and type 2 diabetes. The resident was assessed as having intact cognition. Interviews with facility staff, including an MDS LVN and the ADON, confirmed that the resident's oxygen use was not documented in the care plan and acknowledged the importance of including this information to ensure care needs are met. The facility's own policy requires care plans to be reviewed and revised after each assessment and in response to changes in the resident's needs, but this process was not followed in this instance.