Failure to Implement Hospital Transfer Orders for Respiratory Care
Penalty
Summary
The facility failed to follow hospital transfer orders for a resident with diagnoses including unspecified asthma, obesity hypoventilation syndrome, and chronic respiratory failure. Upon observation, the resident was found in bed without oxygen, CPAP, or BIPAP in use, despite hospital transfer orders specifying continuous oxygen at 4 liters per minute by nasal cannula and instructions for CPAP/BIPAP. The resident's care plan only indicated oxygen 1-4 liters as needed, and treatment records for April and May did not document continuous oxygen therapy as ordered. Review of the facility's electronic medication record revealed that the hospital diagnoses and instructions for CPAP/BIPAP were not present or implemented. LPN staff confirmed that the general instructions and orders for oxygen and CPAP/BIPAP from the hospital were not carried out.