Failure to Follow Care Plans and Physician Orders for Diet, Oxygen, and Equipment
Penalty
Summary
Facility staff failed to follow physician orders and care plan interventions for three residents, resulting in deficiencies related to diet, oxygen therapy, and assistance with meals. One resident with diagnoses including encephalopathy, dementia, Alzheimer's disease, and dysphagia was observed receiving milk that was not thickened as required by her prescribed pureed, nectar-thickened diet. Staff interviews confirmed that the milk should have been thickened, and the dietary manager stated that CNAs were responsible for ensuring correct diets and fluids were provided. Another resident with alcoholic cirrhosis, dyspnea, and chronic kidney disease was not assisted with meal tray setup as required by her care plan, and was served orange juice despite being on a renal diet, which was confirmed by both the CNA and dietary manager. Additionally, this resident was observed multiple times without her prescribed oxygen therapy, with her oxygen concentrator turned off and her oxygen saturation levels dropping to 84% before staff reapplied oxygen as ordered. A third resident with chronic obstructive pulmonary disease and acute respiratory failure had a physician's order and care plan intervention for maintaining bilateral ear cushions on her nasal cannula. Multiple observations throughout the day revealed that the resident was wearing a nasal cannula without the required ear cushions, and this was confirmed by an LPN during interview and record review.