Failure to Update Care Plan and Medical Records After New Oxygen Therapy Orders
Penalty
Summary
The facility failed to revise the care plan for a resident receiving oxygen therapy when new physician orders were received following a hospital discharge. The resident, who had a history of acute respiratory failure with hypoxia and intact cognition, was observed on multiple occasions with oxygen flow rates set at 3 L/min, despite a new physician order specifying oxygen at 1-2 L/min during the day and 2 L/min at night. The care plan and medical records, including the Order Summary Report and Medication Administration Record, were not updated to reflect the new order, and staff continued to administer oxygen at the previous rate of 2 L/min or higher. Staff did not verify the actual flow rate against the updated physician order, nor did they document the amount of oxygen being administered as required. Interviews revealed that direct care staff were not permitted to adjust the oxygen flow rate and only switched the tubing between devices, while a registered nurse was unaware of the updated order and did not ensure the MAR matched the current physician instructions. The administrator confirmed that the medical record was not consistent with the most recent physician order and was unaware of the change. The facility's oxygen administration policy required a physician order and licensed nurse oversight but did not specify documentation procedures for the amount of oxygen administered. No care plan policy was provided during the survey.