Failure to Administer Ordered Respiratory Treatment
Penalty
Summary
The facility failed to provide respiratory services as ordered for one of nine sampled residents. According to the facility's policy and procedure for oxygen administration, staff are required to adjust the oxygen delivery device for comfort and proper flow, and to observe the resident upon setup and periodically thereafter. Medical record review revealed that a resident with diagnoses including acute respiratory distress syndrome and chronic respiratory failure with hypoxia had a physician's order for Ipratropium-Albuterol inhalation solution to be administered via nebulizer every four hours. On a specific date, the medication was not administered to the resident as ordered, as evidenced by a blank entry on the Medication Administration Record (MAR). This omission was confirmed through interviews and concurrent medical record reviews with the RT Supervisor, an RN, and the ADON, all of whom verified that the breathing treatment was not given at the scheduled time. The Administrator also verified these findings during an interview.