Failure to Obtain Physician Orders for Respiratory Equipment Settings
Penalty
Summary
A deficiency occurred when the facility failed to ensure that care and treatment for a resident with a tracheostomy and requiring continual respiratory care were consistent with professional standards of practice. Specifically, nursing staff did not obtain physician's orders for the Airvo respiratory equipment settings, the type of water to be used in the device, or the frequency for monitoring the water chamber to prevent it from running dry. The facility's protocol required documentation of Airvo flow settings, oxygen liter flow, oxygen percentage, and the patient's tolerance to therapy, but these were not supported by corresponding physician's orders in the resident's medical record. The resident involved had a history of large intracranial hemorrhage, acute hypoxic respiratory failure, and a tracheostomy, and was admitted to the facility with ongoing respiratory needs. Upon admission, a respiratory therapist set up the Airvo unit, after which nursing staff were responsible for monitoring the device. However, interviews revealed that the necessary physician's orders for the respiratory equipment were incomplete at the time of admission, and nursing had not obtained them as required.