Failure to Update Care Plan After Resident Desaturation and Vomiting Episode
Penalty
Summary
The facility failed to revise a comprehensive care plan for a resident after a significant change in condition involving desaturation and vomiting. The resident was admitted with diagnoses of heart failure, epilepsy, and COPD, and had moderately impaired cognitive functioning, requiring staff assistance for toileting hygiene, toilet transfers, showers, and lower body dressing. On review of the resident’s MDS and admission records, these needs and conditions were documented. The facility’s policy required that the comprehensive, person-centered care plan, which includes measurable objectives and timetables to meet physical, psychological, and functional needs, be reviewed and updated when there is a significant change in condition or when a resident is readmitted from a hospital stay. On a specific date, an SBAR Communication Form documented that the resident experienced an episode of vomiting and an oxygen saturation of 76% on room air, and was transferred to a general acute care hospital for further evaluation. During an interview and concurrent record review, an RN confirmed that the resident’s care plan had not been updated to address the episode of vomiting and desaturation. The RN stated that the care plan is an essential guide for staff to provide monitoring to ensure the resident’s condition does not deteriorate and acknowledged that the failure to update the care plan had the potential to delay care and monitoring for the resident.
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