Failure to Update Care Plan and Orders for Oxygen Therapy
Penalty
Summary
The facility failed to revise and update the care plan to include a new order for oxygen usage for one resident following a hospital discharge. Observations showed the resident was using oxygen via nasal cannula on multiple occasions, but a review of the Medication Administration Record and current physician orders did not show any documentation for oxygen usage. Additionally, the resident's care plan did not include information regarding oxygen therapy, despite the resident having a recent hospital discharge order for oxygen. Interviews with the ADON and DON confirmed that the oxygen order from the hospital discharge had been noted but was not entered into the resident's orders or care plan. The facility's policy requires the interdisciplinary team to develop and revise comprehensive care plans to reflect changes in orders or resident condition, but this was not followed in this case. The resident had diagnoses of anemia, cancer, and malnutrition, and was assessed as having no cognitive impairment.