Failure to Obtain Physician Orders and Administer Respiratory Care as Ordered
Penalty
Summary
The facility failed to obtain necessary physician orders for the use of respiratory equipment for two residents and did not administer oxygen therapy as ordered for a third resident. One resident with a history of acute and chronic respiratory failure and obesity hypoventilation syndrome was admitted with instructions from the hospital to use a BiPAP machine at night and during naps. Despite the resident using the BiPAP machine nightly since admission, there was no physician order for its use, and the Medical Director was unaware the resident was using the device. The facility administration acknowledged that an order should have been requested at admission but was not. Another resident with a diagnosis of sleep apnea was observed using a CPAP machine, which she brought from home and used nightly. Nursing documentation confirmed the use of the CPAP, but there was no physician order for its use. The Medical Director was also unaware of this resident's use of the CPAP machine, and facility leadership confirmed that an order should have been obtained at admission but was not. A third resident with a tracheostomy had a physician order for oxygen at 4L per minute via tracheostomy to maintain oxygen saturation above 90%. However, the resident was consistently observed receiving oxygen at 3L per minute via nasal cannula, not as ordered. Nursing staff documented that the resident was receiving oxygen as ordered, but in interviews, admitted to providing oxygen via nasal cannula at a lower rate due to the resident's preference. The Medical Director and facility staff were not informed of the change in administration, and the care plan was not updated to reflect the actual practice or the resident's preference.