Failure to Provide and Document Ordered AVAPS Therapy and Oxygen Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care to a resident according to professional standards of practice, specifically related to AVAPS therapy and oxygen administration. The resident had a significant medical history including toxic encephalopathy, COPD with exacerbation, acute and chronic respiratory failure with hypoxia and hypercapnia, pneumonia, and dementia, and had a BIMS score indicating intact cognition. Physician orders directed that the resident receive AVAPS via a Trilogy V60 ventilator at bedtime with specific settings, that refusals of AVAPS be documented each evening and night shift, and that oxygen be administered at 3 L/min via nasal cannula with SpO2 maintained between 88%–92% each shift. The facility’s own respiratory therapy policy required staff to collaborate with the interdisciplinary team and document assessments, treatments, resident response, and education in the medical record. Review of the electronic treatment administration record (e‑TAR) for February showed that the resident’s SpO2 levels were documented between 94%–99%, which was inconsistent with the physician’s ordered target range of 88%–92% for a COPD resident on AVAPS. Between February 17 and February 25, of 15 required evening/night AVAPS applications, 8 shifts (53%) had missing or unclear documentation of treatment or refusal, and there were also missing entries for cleaning the resident’s respiratory appliances on specified day shifts. The e‑TAR contained entries of “N/A” and “0” for AVAPS application on several evening and night shifts, and the DON could not clarify what these notations meant. The care plan documented AVAPS use and respiratory monitoring interventions, and later noted that the resident refused AVAPS at times, but there were no follow‑up interventions related to refusals, and the clinical record lacked evidence that AVAPS refusals were communicated to the physician. Nursing notes documented that on one evening the resident’s pulse oximetry dropped to 60% and the resident was noted to be confused, at which time AVAPS was applied. Progress notes indicated that the resident had refused AVAPS during the prior night shift, while the e‑TAR for that same period showed AVAPS as applied, demonstrating conflicting documentation. The resident was subsequently transferred to the emergency room for shortness of breath, with CO2 measured at the upper end of normal (45 mmHg), and was later readmitted and placed on AVAPS with 3 L oxygen. An NP interviewed during the survey stated she was unaware of the physician orders regarding AVAPS frequency and oxygen parameters. Based on these findings, surveyors concluded that the facility failed to consistently administer and appropriately document life‑sustaining AVAPS therapy and physician‑ordered oxygen parameters, resulting in actual physical harm and significant clinical decline for the resident, including acute respiratory distress, mental confusion, and elevated CO2 levels that necessitated emergency transfer.
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