Failure to Perform Required Respiratory Assessments During Medication Administration
Penalty
Summary
A deficiency occurred when a resident with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) did not receive appropriate respiratory assessments as required by physician orders during medication administration. The resident, who was cognitively intact, had active orders for Albuterol nebulizer treatments and Symbicort inhaler, with specific instructions to check lung sounds, pulse, and respirations before and after nebulizer administration, as well as to rinse and spit after inhaler use. During a medication pass observation, the LPN administered oral medications, the inhaler, and the nebulizer treatment but failed to check lung sounds or assess respirations before or after the nebulizer treatment. Additionally, the resident was not provided water to rinse and spit after the inhaler, as required by the order. When interviewed, the LPN acknowledged that she should have performed the respiratory assessments and checked oxygen levels but forgot due to nervousness. Documentation in the record indicated that the LPN had charted the assessments despite not performing them. The DON confirmed that the expected practice was to assess lung sounds, oxygenation, and respirations before and after respiratory treatments and agreed that the LPN did not follow the required procedures for this resident.