Failure to Obtain Physician Order and Maintain Sanitary Storage for Incentive Spirometer
Penalty
Summary
Facility staff failed to provide appropriate respiratory care and services for one resident by not obtaining a physician's order for the use of an incentive spirometer. The resident's clinical record did not contain an order for the device, and the admission minimum data set assessment was incomplete. The resident was alert and oriented at the time of admission, and a clinical admission assessment was documented, but there was no documentation supporting the use of the incentive spirometer as ordered by a physician. During observation, the incentive spirometer was found on the resident's nightstand with the mouthpiece uncovered, and the resident confirmed using the device without staff providing a cover. An LPN interviewed stated that a physician's order is required for incentive spirometer use, including frequency, and that the device should be stored in a plastic bag for infection control. The facility did not provide a policy regarding incentive spirometer use, and no further information was presented before the survey exit.