Failure to Revise Care Plan Following Change in Oxygen Therapy Needs
Penalty
Summary
A deficiency was identified when the facility failed to revise the comprehensive care plan for a resident following a significant change in their condition. Clinical record review showed that the resident had a recent MDS assessment indicating the use of oxygen therapy, with a physician's order for supplemental oxygen at two liters per minute via nasal cannula every shift, and instructions to monitor oxygen saturation to keep it above 90 percent. The care plan included interventions for continuous oxygen use and medication administration as ordered, with monitoring for side effects and effectiveness. However, during observations on two separate occasions, the resident was found in bed without supplemental oxygen being administered. The resident confirmed in an interview that they were not utilizing the supplemental oxygen. Further interviews with the DON and Regional Director of Clinical Services revealed that the oxygen order was based on oxygen saturation, which had consistently been above 95 percent. Despite these changes in the resident's needs and interventions, the care plan was not updated to reflect the current status, resulting in a failure to revise the comprehensive care plan as required.