Failure to Provide Ordered Incentive Spirometer for Post-Surgical Resident
Penalty
Summary
The facility failed to provide a prescribed incentive spirometer (IS) to a resident who had recently undergone cervical spinal fusion surgery and was at risk for pulmonary complications. The resident's physician had ordered the use of the IS three times per day for ten days to prevent pneumonia and other lung issues. Observations on multiple occasions revealed that the IS device was not present or available for the resident's use, and the resident confirmed he had not used the device. A licensed nurse acknowledged the absence of the IS and confirmed that it had not been provided as ordered. Further review with the Director of Nursing confirmed the existence of the physician's order for IS use and the expectation that nursing staff would provide the necessary care and equipment. The facility was unable to produce a policy regarding the use of breathing devices such as the IS. Additionally, a review of the RN's duties indicated a requirement to maintain adequate medical supplies and equipment to meet residents' needs, which was not met in this instance.