Failure to Update Care Plans Following Physician Order Changes
Penalty
Summary
The facility failed to accurately update the care plans for two residents following changes in their physician's orders. For one resident, physician's orders included specific instructions for nutritional support via PEG tube, including the administration of Ensure Original three times daily and Jevity 1.5 at a specified rate overnight. However, the resident's care plan only noted a mechanically altered therapeutic diet and water flushes and medications via PEG tube, without reflecting the updated nutritional orders. For the second resident, physician's orders required oxygen at 3 liters per minute via nasal cannula as needed to maintain oxygen saturation above 90%. The care plan, however, indicated continuous oxygen at the same rate, not reflecting the as-needed order. Interviews with the MDS Nurse, DON, and Administrator confirmed that the process for updating care plans was not followed, and new or updated physician's orders were not incorporated into the residents' care plans as required by facility policy.