Care Plan Not Updated After Discontinuation of Breathing Treatment
Penalty
Summary
A deficiency was identified when the facility failed to update a resident's comprehensive care plan to reflect current care needs and interventions. Specifically, the care plan was not revised after the discontinuation of a physician's order for a breathing treatment (ipratropium-Albuterol solution via nebulizer) that had been prescribed for shortness of breath. The care plan continued to reference the breathing treatment even after the order had ended, contrary to the facility's policy requiring care plans to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment. The issue was discovered during an observation and interview with the resident, who reported using a nebulizer at bedside for breathing problems. The nebulizer and mask were observed in the resident's room, and a review of the medical record confirmed the breathing treatment order had been discontinued. The Director of Nursing was informed and verified these findings, confirming that the care plan had not been updated to reflect the change in the resident's treatment regimen.
Plan Of Correction
4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance. Integrate QA Process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025