Failure to Implement Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical needs, including acute respiratory failure with hypoxia, dementia, and significant mobility limitations. The care plan specified that the resident required oxygen therapy at 2-4 liters per nasal cannula and mechanical lift transfers with two-person staff assistance. However, staff did not follow the care plan during observed care. On one occasion, two CNAs transferred the resident from bed to wheelchair using a gait belt instead of the required mechanical lift, citing the unavailability of a mechanical lift sling. Both CNAs acknowledged that the resident typically required a mechanical lift and that the deviation from the care plan was reported to the charge nurse. Additionally, the resident was observed on multiple occasions without her oxygen tubing in place, despite physician orders and care plan directives for continuous oxygen therapy. The oxygen tubing was found lying across the bed or not on the resident's nasal area while she was in her wheelchair and eating lunch. The resident stated she only wore the oxygen at night, and the ADON confirmed the resident was not wearing the oxygen as ordered, with no documented response to the risk. The facility's policy required care plans to be updated to reflect oxygen use, but there was no evidence this was consistently implemented.