Failure to Update Care Plan After Change in Respiratory Status
Penalty
Summary
The facility failed to revise the care plan for one resident to reflect a significant change in respiratory status following the discontinuation of ventilator support and the initiation of oxygen therapy via tracheostomy. The resident, who had a history of sepsis, urinary tract infection, ESBL, tracheostomy, and gastrostomy, was originally admitted and later readmitted with these diagnoses. Physician orders indicated the resident was to receive four liters per minute of humidified oxygen via tracheostomy, and the Minimum Data Set documented severe cognitive impairment and high levels of dependence for daily activities. Despite the resident being weaned off the ventilator in the hospital and currently receiving oxygen via tracheostomy, the care plan continued to focus on ventilator dependence and was not updated to reflect the current respiratory needs. This was confirmed during interviews and record reviews, where the DON acknowledged the care plan required revision to ensure appropriate care and staff implementation. The facility's policy required care plans to be updated with changes in resident status, but this was not done in this case.