Failure to Implement Physician Orders for Respiratory Care
Penalty
Summary
The facility failed to implement physician orders for appropriate respiratory care for a resident with significant respiratory needs. Upon admission, the resident had diagnoses including acute respiratory failure, tracheostomy, pneumonia, intracerebral hemorrhage, and functional quadriplegia, and was dependent for all care. Medical record review showed there were no physician orders for tracheostomy care or oxygen administration documented in the resident's baseline care plan, progress notes, admitting physician's orders, or the Treatment Administration Record. Staff interviews confirmed that the resident was admitted from a subacute care hospital with a tracheostomy in place and was receiving oxygen, but no orders for tracheostomy care or oxygen administration were obtained or implemented upon admission. Facility staff, including an LPN, relied on nursing judgment to determine the administration and flow rate of oxygen for the resident, rather than following physician orders. When the resident experienced respiratory distress and had a low oxygen saturation, the LPN increased the oxygen flow rate based on a physician's phone instruction and called emergency services. The facility's policy required tracheostomy care to be provided according to physician orders and professional standards, but this was not followed in the resident's case.