Failure to Consistently Administer Ordered Respiratory Treatments
Penalty
Summary
The facility failed to consistently provide prescribed respiratory treatments for a resident with severe cognitive impairment and multiple medical diagnoses, including dementia, cerebral infarction, and aphasia. The resident was ordered to receive Volara System therapy with sodium chloride inhalation twice daily, as documented in the electronic medical record. However, review of the device's digital therapy log revealed that 22 treatments were missed over a period of approximately one month. The missed treatments included both morning and evening doses, and there was no documentation provided to explain these omissions. The facility was also unable to provide the requested Respiratory Policy to the surveyor during the investigation. Interviews with the resident's Power-of-Attorney, the respiratory therapist, and the nurse practitioner confirmed concerns about inconsistent administration of the respiratory therapy, particularly during evenings and weekends when the respiratory therapist was not present and nursing staff were responsible. The resident's POA reported increased congestion and wheezing when treatments were missed, which led to a chest x-ray being ordered. Both the respiratory therapist and nurse practitioner stated that it was their expectation for nursing staff to follow provider orders to maintain the resident's health and well-being.