Care Plan Not Updated After Discontinuation of Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised after each assessment, as required. A review of the medical record for a resident with diagnoses including Alzheimer's Disease, Epilepsy, Gastrostomy, and Quadriplegia showed that the care plan continued to include interventions for oxygen administration, even though the physician's order for oxygen had been discontinued several months prior. The care plan still listed oxygen settings and instructions to administer oxygen as ordered, despite the absence of a current order. Interviews with staff confirmed that the care plan was not updated following the discontinuation of oxygen therapy, and acknowledged that it should have been revised after each assessment.