Care Plan Not Updated to Reflect Physician-Ordered Edema Interventions
Penalty
Summary
The facility failed to ensure an existing care plan was revised to reflect current physician-ordered interventions for a resident with acute and chronic respiratory failure and other breathing abnormalities. The resident, who reported that his left arm had been swollen "for a while," had a physician order dated 9/16/25 for a compression glove to the left hand and a Tubi grip sleeve to the left arm from wrist to shoulder to be applied every day and night shift for edema. On multiple observations, the resident was seen sitting in his room without the ordered compression glove and Tubi grip sleeve in place. Review of the resident’s care plan showed no documentation regarding the compression glove or Tubi grip sleeve, despite the active physician order. The RN Clinical Resource Nurse acknowledged that the care plan should have been updated when the physician orders for these edema interventions were received and that it had not been updated.
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