Failure to Provide and Document Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for five residents with significant respiratory diagnoses, including acute and chronic respiratory failure, COPD, obstructive sleep apnea, and dependence on supplemental oxygen. For each of these residents, physician orders were in place for oxygen therapy, specifying parameters such as flow rates and oxygen saturation targets. However, the care plans for these residents did not include interventions related to oxygen use or the use of respiratory support devices such as BiPAP or CPAP machines, despite their documented need for such interventions. Record reviews revealed that the medication administration records (MARs) for these residents did not document when or how much oxygen was administered, making it impossible to verify compliance with physician orders. In several cases, residents were observed using oxygen or reported using it as needed, but there was no corresponding documentation in the MAR or care plan. Interviews with facility staff, including the Unit Manager and Nurse Manager, confirmed that care plans lacked necessary interventions for oxygen therapy and that documentation of oxygen administration was absent from the electronic health record (EHR). Additionally, staff interviews indicated that some residents were on continuous oxygen, yet their orders were written as PRN (as needed), which was acknowledged as inappropriate by the Unit Manager. The lack of documentation and care planning for oxygen therapy and respiratory support devices was consistent across all five residents reviewed, despite their complex respiratory needs and physician orders requiring close monitoring and intervention.