Failure to Assess and Care Plan for Resident Self-Administration of Nebulizer Treatments
Penalty
Summary
The facility failed to obtain physician orders, conduct assessments, or develop care plans for two residents who were self-administering nebulizer treatments. Observations revealed that both residents independently managed their nebulizer treatments without nursing staff remaining present during administration, as required by facility policy. In both cases, the nebulizer equipment was left un-bagged on bedside tables after use, and the residents reported that nurses provided the medication and set up the equipment but did not stay in the room during the treatment. Review of the medical records for both residents showed no physician orders authorizing self-administration of nebulizer treatments, no documentation of assessments to determine their ability to self-administer, and no care plan interventions addressing self-administration. Both residents had diagnoses including COPD and required respiratory treatments, with cognitive assessments indicating intact cognition. However, their care plans only addressed general respiratory care and did not include any provisions for self-administration of medications or storage arrangements for nebulizer equipment. Interviews with staff, including an LPN and the DON, confirmed that the facility did not have any residents formally assessed or care planned for self-administration of nebulizer treatments. The DON stated that the process for nebulizer treatments required nursing staff to remain with the resident throughout the procedure, and that any resident self-administering should have an order, assessment, and care plan in place. Facility policies also required interdisciplinary team assessment and documentation before allowing self-administration, none of which were completed for the residents involved.