Failure to Implement Physician Orders for Lung Treatment
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice by not following physician orders for a medical treatment for a resident with chronic lung conditions. Resident 15, who was admitted with diagnoses including pneumothorax and post coronary artery bypass, had a physician's order dated November 18, 2024, to use an incentive spirometer every two hours while awake. This device is intended to exercise the lungs and prevent infections by expanding them. However, a review of the resident's medication and treatment administration records from November 18, 2024, through December 17, 2024, showed no documented evidence that the spirometry orders were implemented. The deficiency was further highlighted when the facility received a call from the resident's thoracic surgeon on December 17, 2024, indicating that the resident's chest tube was not draining and the lung was not expanded, an issue that had persisted since the resident's hospital stay. The Director of Nursing confirmed during an interview on December 18, 2024, that there was no documented evidence of the spirometry treatment being carried out as prescribed. This lack of adherence to the physician's orders and failure to document the treatment contributed to the deficiency identified by the surveyors.
Plan Of Correction
Step 1 - Unable to retroactively fix this issue for resident 15. Step 2 - Review of residents in facility to assure there are no other residents that are using incentive spirometry without orders. DON or designee Step 3 - Education to nursing staff on need for orders from MD and documentation requirements for resident who are to utilize special equipment. Staff Educator or Designee Step 4 - Random audits of resident requiring special equipment to assure MD orders and required documentation is in place. Weekly times 4 monthly times 2 - DON or Designee Step 5 - Results to QAPI Monthly times 2