Failure to Update Care Plans After Falls, Oral Care Changes, and Oxygen Therapy
Penalty
Summary
The facility failed to update and revise care plans for two residents following significant changes in their conditions and care needs. For one resident with schizophrenia and dementia, the care plan was not updated after multiple falls, including a recent incident where the resident was found unconscious with a hematoma and required hospital evaluation. The fall investigation documentation was incomplete, lacking supervisor review and signatures, and there was no evidence that the care plan was revised to address new interventions or needs following the fall or after the resident's return from the hospital. Additionally, the same resident's care plan did not reflect current oral care needs and preferences, despite a dental exam noting moderate plaque, gingivitis, and buildup on the teeth. Observations over several days confirmed visible buildup on the resident's gumline, and staff interviews revealed that the resident preferred to perform oral care independently but required assistance. The care plan was not updated to reflect these preferences or the findings from the dental evaluation. For another resident with acute respiratory failure and hypoxia, the care plan did not include specific interventions for oxygen use, despite physician orders for continuous oxygen therapy and observations confirming ongoing oxygen use. The care plan only referenced checking oxygen saturation but did not address the need for or management of oxygen therapy. The DON confirmed that the care plan should have been updated to reflect these interventions, but no explanation was provided for the omission.