Failure to Monitor and Document Respiratory Care Orders
Penalty
Summary
The facility failed to ensure proper monitoring and administration of respiratory care for a resident with significant medical needs, including quadriplegia, a tracheostomy, and a cervical spine injury. Physician orders for oxygen at two liters humidified air via trach mask, suction every shift and as needed, and monthly trach inner cannula changes were not transcribed into the medical record, resulting in a lack of documentation regarding when these interventions were completed and monitored. Additionally, there was limited documentation of oxygen saturation readings in the resident's vital records. Interviews with nursing staff and the President of Clinical Services confirmed that the necessary respiratory care orders were missing from the medical record, leading to insufficient monitoring and documentation of the resident's respiratory status. Facility policy requires monitoring of oxygen saturation to assess and respond to respiratory changes, but this was not followed in this case.