Failure to Develop and Update Care Plans for Respiratory and Fall Risk Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing the specific needs of residents in the areas of respiratory care and fall prevention. For one resident with chronic obstructive pulmonary disease and obstructive sleep apnea, the medical record showed the use of a CPAP machine and nebulizers, but there was no evidence of a care plan covering these respiratory interventions. Another resident was observed using oxygen at varying flow rates, yet the care plan did not reflect the physician's order for oxygen therapy, nor did it document the resident's use of oxygen as observed by surveyors. Additionally, a resident with a history of dementia, vertigo, osteoporosis, anxiety, and previous falls with fracture was found to have a fall mat in use, but the care plan did not include this intervention. The absence of documentation for the fall mat as a preventive measure was confirmed by the Director of Nursing. These omissions indicate that the facility did not ensure care plans were updated to reflect current physician orders and observed interventions for residents with respiratory needs and fall risks.