Failure to Revise and Update Individualized Care Plans for Oxygen Use and Fall Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure ongoing revision and updating of individualized care plans in accordance with residents’ conditions and treatments. For one resident with diagnoses including Alzheimer’s disease, dementia, adult failure to thrive, type 2 diabetes mellitus, and chronic ischemic heart disease, surveyors observed the resident lying in bed with oxygen in use at 2L via nasal cannula. The oxygen tubing had no label with a date, there was no physician order for oxygen administration in the active orders, and there was no care plan addressing oxygen use. The DON acknowledged that oxygen use should have a physician’s order and that the tubing should be labeled with a date, and the Administrator was informed that there was no care plan for the oxygen therapy. Another resident, an older adult with multiple diagnoses including chronic respiratory failure with hypoxia, tracheostomy and ventilator dependence, gastrostomy, left femur fracture with routine healing, essential hypertension, seizure disorder, anxiety disorder, depressive disorders, generalized edema, left hip pain, diaphragmatic hernia, and delirium, was identified as being at high risk for falls per a Fall Risk scale. The resident’s fall care plan, initiated for high fall risk with problems such as gait/balance issues, poor communication/comprehension, decreased safety awareness, and adverse behaviors, contained dated interventions such as keeping furniture locked, educating the resident to use the call light, and bilateral floor mats. However, on subsequent dates, entries of 11/29/25 and 12/1/25 documented “no intervention” instead of updated fall-prevention measures after falls. The DON stated that the fall care plan should be updated after each fall with appropriate interventions, and the Administrator stated that his expectation is that care plans be updated after appropriate interventions are discussed, indicating that this did not occur as required by facility policy for comprehensive care plans.
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