F0842

D

Incomplete Respiratory Treatment and Ventilator Documentation for Ventilator-Dependent Residents

Newbury, Ohio Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate and complete medical records and respiratory treatment documentation for three ventilator‑dependent residents with tracheostomies. For one resident with acute respiratory failure, sepsis, heart failure, tracheostomy, and ventilator dependence, the Respiratory Treatment Record (RTR) contained numerous blanks for ordered ventilator checks scheduled every six hours and as needed across multiple days in February and March. Additional blanks were found for ordered oxygen equipment changes, nebulized sodium chloride and budesonide treatments, ipratropium‑albuterol treatments, tracheostomy assessments each shift, tracheostomy care twice daily, daily inner cannula changes, oxygen administration and monitoring, tracheostomy collar setup changes, and cough assist treatments. The resident’s care plan included oxygen therapy, tracheostomy care, and ventilator dependence with related interventions, but did not include the specific intervention for ventilator checks every six hours.

A second resident, also cognitively intact and dependent in ADLs with acute respiratory failure, heart failure, tracheostomy, and ventilator dependence, had similar documentation gaps. The RTR for this resident showed missing entries for ordered ventilator checks every six hours and as needed, as well as for scheduled albuterol nebulization treatments and sodium chloride nebulization treatments. There were also blanks for ordered tracheostomy cuff assessments every shift and oxygen orders intended to maintain oxygen saturation at or above 88 percent. The resident’s care plan documented oxygen therapy, ventilator dependence, and tracheostomy care with associated interventions such as administering medications and aerosol treatments as ordered, monitoring oxygen saturation, and assessing for signs of hypoxia, but did not address the specific requirement for ventilator checks every six hours.

The third resident, with extensive diagnoses including acute and chronic respiratory failure, CHF, COPD, interstitial lung disease, dysphagia, myasthenia gravis, non‑Hodgkin lymphoma, dementia, and CKD, and who had a tracheostomy and was ventilator‑dependent, also had incomplete documentation. For this resident, the RTR contained multiple blanks for ordered ventilator checks every six hours and as needed, both before and after a hospital discharge and readmission. There were additional blanks for ordered albuterol nebulization and later ipratropium‑albuterol aerosol treatments, as well as for oxygen titration orders to maintain oxygen saturation of 88 percent or greater every shift. The care plan for this resident identified tracheostomy and ventilator dependence with interventions including aerosol treatments as ordered, suctioning as necessary, and monitoring and documenting respiratory status every shift.

Interviews with the ADON and a respiratory therapist confirmed that an RT was always present in the facility and that RT staff were expected to document on the RTR when orders were completed, omitted, refused, or not completed for any reason. They verified the blanks on the RTRs for all three residents and stated they believed the orders were completed but not documented, and confirmed there was no other documentation used for ventilator checks beyond the RTR. The DON also verified the presence of blanks on the RTRs for ventilator checks, aerosol treatments, tracheostomy assessments, and oxygen orders, and stated that a medication error form should have been completed for any omitted treatment or medication. The Director of Respiratory Therapy acknowledged noticing the blanks, stated that RT staff were not used to documenting on the RTR and that she herself had not documented at times, and confirmed that the RTR documentation was not accurate. Facility policies on medication errors and invasive mechanical ventilation were reviewed; the medication error policy required completion of a medication error/omission report when an error was discovered, and the invasive mechanical ventilation policy did not address ventilator checks or documentation requirements on the RTR.