Failure to Follow Physician Orders for Respiratory Care and Inadequate Documentation
Penalty
Summary
The facility failed to follow physician orders for respiratory care for one resident requiring supplemental oxygen and CPAP/BIPAP treatments. The resident's clinical record included a provider order to check oxygen saturation (SpO2) four times per shift and to notify the covering provider if SpO2 dropped below 90% while awake or below 88% when sleeping. Multiple nursing narrative notes documented SpO2 readings below these thresholds on several occasions, but there was no evidence in the clinical record that the covering provider was notified as required by the order. Additionally, the resident had orders for CPAP use at bedtime, but observations and interviews revealed unclear documentation regarding whether the resident should use CPAP or BIPAP at times other than bedtime, and whether supplemental oxygen should be attached to the CPAP/BIPAP machine during use. The Director of Nursing confirmed that the provider orders were not clear regarding the timing and method of CPAP/BIPAP use and that the required notifications to the provider were not documented when low SpO2 readings occurred.