Failure to Update Care Plans for Oxygen Therapy and Leg Immobilizer Use
Penalty
Summary
The facility failed to revise and update the care plans for two residents to reflect significant changes in their care needs, specifically regarding the use of oxygen therapy and a leg immobilizer. For one resident with a history of hypertension, muscle weakness, atrial fibrillation, and bone disorders, the care plan did not include specific instructions for the use and monitoring of a leg immobilizer, nor did it address the presence of skin breakdown caused by the device. Despite physician orders specifying when the immobilizer should be removed and documentation of open sores on the resident's leg, the care plan lacked guidance for staff on daily skin monitoring and wound care. Staff interviews revealed a lack of awareness about the resident's skin condition, inconsistent dressing changes, and improper use of protective barriers between the immobilizer and the skin. Another resident, diagnosed with hemiplegia, hemiparesis, chronic respiratory failure with hypoxia, and other conditions, had a care plan that failed to include the use of prescribed oxygen therapy. Although the resident was receiving oxygen via nasal cannula and had physician orders for oxygen administration, the care plan only referenced the use of CPAP and nebulizer treatments. Observations confirmed the resident was using oxygen, and staff acknowledged that the care plan should have included this intervention. Additionally, equipment such as oxygen tubing, nebulizer, and CPAP were not properly stored or cleaned when not in use. The facility's own policy required comprehensive, person-centered care plans to be developed and revised as residents' conditions changed. However, in both cases, the care plans were not updated to reflect current physician orders or the residents' actual care needs, resulting in a lack of clear direction for staff and placing the residents at risk for unmet care needs.