Failure to Provide Ordered Respiratory Care and Documentation
Penalty
Summary
A deficiency occurred when the facility failed to provide respiratory care as ordered for a resident with acute respiratory failure with hypoxia and idiopathic pulmonary fibrosis. The physician's order specified that oxygen should be administered continuously at 2 liters per minute via nasal cannula. However, review of the Medication Administration Record (MAR) for the relevant period showed no documentation that the oxygen was administered as ordered from 11/22/25 through 11/24/25. Nursing progress notes also did not specify whether the resident was receiving oxygen at the time of a noted change in condition. Interviews with staff and the Director of Nursing confirmed the lack of documentation and implementation of the oxygen order. The resident was described as cognitively intact and was able to answer questions appropriately earlier in the day. On the day of the incident, the resident became lethargic, and family members requested transfer to the hospital. The DON verified the absence of an admission assessment, a transfer out assessment, and any documented investigation into the resident's change in condition.