Failure to Revise Care Plan to Reflect PRN Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to revise and maintain an accurate care plan regarding a resident’s oxygen use. The resident was admitted with COPD, type 2 diabetes mellitus, and dementia. A physician’s order dated 08/14/25 directed oxygen via nasal cannula at 2 L to maintain oxygen saturation above 90%. The resident’s care plan, revised on 12/31/25, documented that the resident used oxygen via nasal cannula at 2 L continuously. However, this care plan was not updated to reflect the resident’s actual pattern of oxygen use. During an observation on 01/28/26, the resident was seen in her room with an oxygen concentrator next to the bed, but she was not wearing the nasal cannula and the machine was turned off. The resident stated she only wears her oxygen when she needs it. In a subsequent interview on 01/30/26, the DON confirmed that the resident only uses oxygen as needed and acknowledged that the care plan was not accurate and should have been revised. This failure to revise the care plan to reflect current oxygen interventions constituted the cited deficiency.
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