Mount Washington Care Center: Respiratory Care Failures - OH

Resident #71 arrived at the facility on July 26 from a subacute care hospital with acute respiratory failure, pneumonia, and a tracheostomy already in place. The resident was severely cognitively impaired and dependent for all care.

The discharge orders from the hospital included no instructions for tracheostomy care or oxygen administration. Neither did the admitting physician write orders for respiratory care when the resident entered Mount Washington.

Licensed Practical Nurse #109 continued giving the resident oxygen at four liters per minute anyway. "The nurse did not receive or implement orders for tracheostomy care or oxygen administration," inspectors found. He relied entirely on nursing judgment.

The next morning, July 27, LPN #109 found Resident #71 in respiratory distress. The resident's oxygen saturation had dropped to 68 percent.

Normal oxygen saturation levels range from 95 to 100 percent. Levels below 90 percent indicate severe oxygen deprivation that can cause organ damage.

LPN #109 called the physician, who told him to increase the oxygen flow rate and call 911. The nurse cranked the oxygen from four liters per minute to seven liters per minute. By the time emergency medical technicians arrived, the resident's oxygen saturation had climbed to 76 percent.

Still dangerously low.

Director of Nursing confirmed the facility had no orders for tracheostomy care or oxygen administration when Resident #71 was admitted. She confirmed the resident was sent to the hospital and admitted with respiratory distress.

The facility's own policy requires tracheostomy care to be provided "according to the physician's orders and in accordance with professional standards of practice." The policy calls for tracheostomy care at least twice daily.

But no orders existed.

Mount Washington staff had been making respiratory care decisions for a resident with acute respiratory failure, pneumonia, and functional quadriplegia without any medical oversight. The Treatment Administration Record for July 2025 contained no orders for oxygen or tracheostomy care.

The resident's baseline care plan noted the tracheostomy and feeding tube but made no mention of respiratory care protocols. Progress notes from the admission date similarly omitted any documentation of physician orders for the life-sustaining respiratory interventions the resident required.

LPN #109 told inspectors he had continued the oxygen therapy he observed when the resident arrived, assuming it was appropriate. When the resident's condition deteriorated overnight, the nurse had no standing orders to guide his response beyond calling the doctor and emergency services.

The Director of Nursing acknowledged that facility staff had "relied on nursing judgment" for both oxygen administration and tracheostomy care. For a resident whose primary diagnoses included acute respiratory failure and pneumonia, this represented a fundamental breakdown in medical oversight.

Federal investigators found the facility failed to ensure implementation of physician orders for appropriate respiratory care. The violation affected one of three residents reviewed for respiratory services during the complaint investigation.

Mount Washington Care Center houses 70 residents. The inspection occurred after a complaint was filed with state health officials.

The facility's tracheostomy care policy, dated 2024, explicitly states that such care must follow physician orders. Tracheostomies require precise, sterile care to prevent infection and maintain airway patency. Without proper medical supervision, residents face risks of airway obstruction, infection, and respiratory failure.

Resident #71's case illustrates these dangers. Despite receiving oxygen therapy, the resident's condition deteriorated to the point of requiring emergency hospitalization within 24 hours of admission.

The inspection report does not indicate whether Resident #71 survived the hospitalization or returned to Mount Washington. It does not specify what respiratory care, if any, the resident received during the three-week stay before the crisis.

What remains clear is that a resident with multiple life-threatening conditions received critical respiratory interventions without any physician oversight for weeks. When the inevitable crisis arrived, staff had no medical guidance beyond their own judgment and a phone call to a doctor who had never written orders for the resident's care.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Mount Washington Care Center from 2025-08-14 including all violations, facility responses, and corrective action plans.

Additional Resources

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