Failure to Obtain Physician Orders for Respiratory Care Devices
Penalty
Summary
The facility failed to obtain and implement physician orders for respiratory care for two residents requiring specialized respiratory support. One resident with a tracheostomy and a speaking valve was observed without any documented physician orders for monitoring, cleaning, or checking the speaking valve, despite having a medical history of tracheostomy status, muscle weakness, and cough. The resident was alert and oriented, and the necessary supplies were present at the bedside, but there was no evidence in the medical record of orders or protocols for the care and maintenance of the speaking valve. Another resident, admitted for skilled rehabilitation following hospitalization for acute respiratory failure with hypoxia, COPD, morbid obesity, diabetes, and pulmonary embolism, did not have physician orders for the use of a BiPAP machine as indicated in their hospital discharge summary. Instead, the resident was provided with a CPAP machine, which is a different type of respiratory support, and there were no physician orders for either device in the facility's records. The resident expressed concern about not having the correct equipment and not receiving an explanation from the nursing staff regarding the change. Interviews with nursing staff and facility leadership confirmed that the process for obtaining and verifying physician orders for respiratory equipment was not followed. Staff acknowledged the absence of orders and the use of incorrect equipment, and there was no documentation or care plan reflecting the resident's prescribed BiPAP therapy. The facility's own policy required physician orders specifying the mode, settings, and frequency of use for positive airway pressure therapies, but these were not present in the residents' records.