Failure to Timely Review and Revise Care Plans for Safety, Hospice, and Oxygen Needs
Penalty
Summary
The facility failed to review and revise care plans in a timely manner for three residents, resulting in deficiencies related to safety needs, hospice care, and oxygen use. For one resident with osteoporosis and a history of falls, the care plan was not updated after an unwitnessed fall in the bathroom, despite multiple falls occurring over several months. The resident was cognitively intact and required staff assistance for transfers and toileting, but the care plan did not reflect new strategies or measures to prevent further falls after the most recent incident. The Director of Nursing confirmed that care planning to prevent falls and promote safety had not been revised accordingly. Another resident had a physician's order for hospice services, but the care plan did not address hospice care, comfort treatment, pain management, psychosocial support, or coordination with the hospice agency. Additionally, a third resident with acute respiratory failure, pulmonary edema, and COPD was observed receiving oxygen at a different rate than what was documented in the care plan. The care plan listed an intervention for 5 liters of oxygen via nasal cannula, while the current physician's order and observation indicated 1 liter. The Director of Nursing confirmed that the care plan was not revised to reflect the current oxygen order.