Failure to Implement Physician-Ordered Respiratory and Tracheostomy Care
Penalty
Summary
The facility failed to provide respiratory and tracheostomy care in accordance with physician orders for a resident diagnosed with chronic respiratory failure and cerebral palsy. The resident had specific physician orders for oxygen as needed to maintain oxygen saturation above 89%, continuous humidification via tracheostomy even when on room air, initiation of vest therapy twice daily for airway clearance, and administration of Albuterol nebulizer twice daily with vest therapy. On observation, the resident was not receiving oxygen or humidification via the tracheostomy, and there was no evidence of a SmartVest in the resident's room. Staff confirmed that humidification was not being used when the resident was on room air and that the resident had not yet received a SmartVest. Further review of the clinical record showed no documentation that arrangements had been made to obtain a SmartVest for the resident, despite the physician's order. The director of nursing was unable to provide evidence that the physician's orders related to respiratory and tracheostomy care were implemented in a timely manner. These findings indicate that the facility did not ensure the resident received the ordered respiratory interventions, as required by the physician's plan of care.