Failure to Implement Respiratory Device Orders on Admission
Penalty
Summary
The facility failed to ensure hospital discharge instructions were reviewed upon admission so that physician orders were in place to meet residents’ medical needs. One resident with chronic respiratory failure with hypoxia and obstructive sleep apnea was admitted with a CPAP machine present in his room and reported using it at night. Surveyors observed the CPAP machine on the resident’s dresser, and the resident confirmed nighttime use. However, the Chief Nursing Officer (CNO) later stated that there was no physician order for the CPAP, and it was not included on the resident’s care plan or Minimum Data Set (MDS), despite the resident’s diagnoses and reported use of the device. Another resident admitted with COPD and chronic kidney disease had an AVAP machine at bedside and stated she used it at night to help her breathe while sleeping. Review of this resident’s hospital transfer orders documented detailed AVAP settings, including IPAP and EPAP ranges, respiratory rate, tidal volume, and oxygen bleed-in parameters with humidification and SpO2 targets, as well as instructions for use each night. Despite these specific hospital discharge instructions, review of the resident’s medical record on a later date showed no physician orders for AVAP use. The CNO confirmed that the AVAP was not on the resident’s orders and acknowledged it should have been, and the survey findings stated that this failure placed the residents at risk of delayed respiratory care and assessments.
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