Failure to Assess Respiratory Status Before and After Inhaler Administration
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), who was cognitively intact, reported feeling short of breath and requested her inhaler. The LPN on duty administered two puffs of albuterol inhaler to the resident in the hallway without performing a respiratory assessment prior to administration. No baseline lung sounds or oxygen saturation (O2 sat) were obtained before giving the medication, and no assessment was conducted after administration to determine the effectiveness of the treatment. Further review of the electronic medication record and medication administration records showed no documentation of a respiratory assessment or O2 sat for the resident on the day in question. The LPN acknowledged that an assessment should have been completed both before and after administering the inhaler. The Director of Nursing confirmed that nursing staff are expected to conduct respiratory assessments for residents reporting shortness of breath and when administering as needed inhaled medications. The facility's policy on medication administered by inhaler did not include instructions for obtaining respiratory assessments before or after administration.