Failure to Update Care Plan with Oxygen Order
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident with multiple chronic conditions was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan did not reflect a current physician's order for oxygen to be administered as needed for shortness of breath or to maintain oxygen saturation above 92%. Despite the presence of this order, the intervention for oxygen as needed was not included in the resident's care plan or in the electronic records accessed by CNAs. Interviews with staff revealed that the omission of the oxygen order from the care plan led to a lack of awareness among CNAs regarding the resident's need for oxygen therapy. The CNAs relied on the electronic care plan for guidance on resident care and did not have access to physician's orders or other medical records. As a result, the CNAs were unaware that the resident required oxygen as needed, and this information was not available in their workflow. The MDS Coordinator and Director of Nurses both acknowledged that the care plan should have been updated to include the oxygen order. The facility's policy required care plans to be revised at regular intervals and when there was a change in a resident's health status. The failure to update the care plan with the current oxygen order placed the resident at risk of not receiving appropriate care and services to maintain her well-being.