Failure to Provide and Document Ordered Respiratory Care
Penalty
Summary
Facility staff failed to provide ordered respiratory care and treatments for two residents. For one resident, there were medical provider orders for the use of an incentive spirometer, including specific instructions for use and monitoring of vital signs and breath sounds before and after each treatment. However, the start date for the treatment was incorrectly entered, and staff could not find documentation that the incentive spirometer was provided or that the orders were carried out. Further investigation revealed uncertainty among staff and the medical provider regarding whether the order was intended for this resident, and no supporting documentation was found in the clinical record. For another resident, who was under hospice care, the hospice plan of care included scheduled nebulizer treatments with albuterol and ipratropium every eight hours. The resident's hospice certification and plan of care confirmed these treatments were to be continued. However, there was no evidence in the clinical record that the nebulizer treatments were administered between the hospice visit and the resident's death. The DON confirmed the absence of documentation for these treatments after reviewing the records. Interviews with facility staff, including the RN who entered the orders, the Medical Director, and the DON, confirmed the lack of documentation and uncertainty regarding the administration of the ordered respiratory treatments. The survey team discussed these findings with facility leadership, highlighting the failure to provide and document required respiratory care as ordered for both residents.