Failure to Document and Assess Resident After Nebulizer Treatment
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, dysphagia, and muscle wasting was not properly monitored following the administration of a nebulizer treatment. The resident had a physician's order for Ipratropium-Albuterol inhalation solution to be given three times daily for shortness of breath. On the date in question, the medication administration record showed the resident received the nebulizer treatment, but there was no documentation of the resident's response to the therapy or any follow-up assessment by the administering RN. Additionally, no vital signs were recorded after the treatment, despite facility policy requiring pulse checks before and after aerosol drug delivery. Interviews with facility staff, including the nurse practitioner and DON, confirmed the expectation that residents should be assessed and have their vitals monitored after receiving respiratory treatments. The RN involved acknowledged she did not follow up with the resident after administering the nebulizer treatment and admitted she should have performed an assessment. Facility policies reviewed also supported the need for thorough documentation and monitoring following respiratory care interventions.