Failure to Update Care Plans for New Edema and Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to revise resident care plans to reflect current physician orders and resident needs, as required by its Resident Care Plan Revisions policy. The policy, revised on 9/3/25, states that updates to the care plan will occur as needed based on the resident’s response to interventions or changes in condition. For one resident with a history including a right tibia fracture and anxiety, a physician order dated 3/6/26 directed edema management of the right lower leg with application of a Tubi grip in the morning and removal in the evening. On multiple observations on 3/30/26 and 4/2/26, the resident was seen sitting in her room without the ordered Tubi grip in place, and during an interview the resident reported that her right lower leg had been swollen for a while. Review of the resident’s care plan and Treatment Administration Record (TAR) on 4/2/26 showed no documentation of the Tubi grip order. A second resident, with diagnoses including COPD, depression, and cardiomegaly, had a physician order dated 3/9/26 for oxygen at 3 LPM continuously via nasal cannula using an oxygen concentrator and/or tank. Review of this resident’s care plan on 4/1/26 showed only prior oxygen interventions: oxygen via nasal prongs at 0–4 L PRN to maintain saturation at 90% or greater, initiated 2/10/25, and oxygen at 2 L/min continuously via nasal cannula, initiated 6/24/25. The more recent continuous 3 LPM oxygen order was not reflected in the care plan. In both cases, the CNO acknowledged that the residents’ care plans (and, for the first resident, the TAR) should have been updated to include the current physician orders but had not been revised.
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