Failure to Provide Ordered Respiratory Care for Resident with Tracheostomy
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician's orders for a resident with chronic respiratory failure, tracheostomy status, and other significant medical conditions. The resident was nonverbal and had limited ability to communicate or understand. Physician orders and hospital discharge instructions required the resident to receive cough assist therapy three times daily to maintain airway patency and lung inflation. Documentation in the Respiratory Administration Record (RAR) showed that the resident missed multiple scheduled cough assist treatments, with reasons cited including lack of tolerance, refusal, being asleep, or being out of the facility. Observations confirmed the presence of a tracheostomy and cough assist machine in the resident's room. Interviews with respiratory therapy staff revealed inconsistent administration of the ordered therapy, with one therapist unable to recall the last time the treatment was attempted. The records indicated at least 20 missed opportunities for cough assist therapy in one month, and additional missed treatments following the resident's hospital readmission, despite ongoing physician orders for the therapy.