Failure to Perform Timely Respiratory Assessments and Accurate Documentation
Penalty
Summary
The facility failed to perform appropriate respiratory assessments for a resident who was dependent on a mechanical ventilator and had multiple complex diagnoses, including chronic respiratory failure with hypoxia, COPD, a history of lung cancer, and end stage renal disease. Upon the resident's readmission, documentation errors were noted, including inaccurate progress notes regarding ventilator settings and the use of outdated vital signs from a previous hospitalization. The respiratory evaluation on the day of readmission recorded vital signs from a prior date, rather than current measurements. Additionally, during the administration of breathing treatments, the respiratory therapist documented pre- and post-treatment vital signs that were several hours old and not reflective of the resident's current status at the time of treatment. The facility's respiratory director confirmed that vital signs should be taken at the time of assessment and treatment, but acknowledged that staff sometimes used previous nursing vital signs due to staffing shortages. The care plan for the resident included monitoring for effectiveness of medications and reporting adverse effects, but the required assessments were not performed as ordered.