Failure to Implement Hospital Discharge Plan for Respiratory Care
Penalty
Summary
Upon admission of a resident with diagnoses including obstructive sleep apnea and acute respiratory failure with hypercapnia, the attending physician did not address the hospital discharge plan that specified the need for CPAP therapy at night and a plan to wean the resident off supplemental oxygen. The initial physician orders only included oxygen inhalation via nasal cannula at 2 liters per minute, with no mention of CPAP use or a structured oxygen weaning protocol as directed by the hospital discharge summary. Subsequent physician documentation referenced the resident's history of obstructive sleep apnea and the need to continue CPAP, but no formal order for CPAP was written at that time, nor was there documentation addressing the plan to wean off oxygen or a rationale for not following the discharge plan. It was not until several days after admission that an order to wean off oxygen was written, and this order did not specify a target oxygen saturation level. An order for nighttime CPAP use was not written until approximately one month after admission. Interviews with the DON revealed uncertainty regarding the reconciliation of hospital discharge plans at admission, and no further clarification was provided to the surveyor before the survey exit. These actions and omissions resulted in a failure to implement the hospital's post-discharge respiratory care plan for the resident.