Failure to Provide Ordered Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care as ordered for a resident with multiple complex diagnoses, including dementia, morbid obesity, end stage renal disease, diabetes, obstructive sleep apnea, and other serious conditions. A physician order was in place for chest physiotherapy and oral suctioning every six hours for 48 hours due to chest congestion. Documentation showed that the initial treatment was administered, but subsequent scheduled treatments were not completed at several required times. The medication administration record indicated missed administrations, with some entries marked as 'other/see nurse notes' and others incorrectly documented as the resident being out of the facility, even though the resident remained in the facility until later that day. Staff interview confirmed that the resident did not receive the ordered respiratory care during the specified times while still present in the facility.