Failure to Document Nebulizer Equipment Maintenance and Respiratory Assessments
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident diagnosed with chronic obstructive pulmonary disease who was receiving nebulizer treatments. Specifically, the clinical record review revealed that there was no documentation of weekly replacement of the nebulizer equipment for the months of December and January, despite physician orders and facility policy requiring this maintenance. Additionally, the resident's record lacked evidence of completed respiratory assessments before and after nebulizer administration in January. Interviews with staff confirmed that respiratory assessments should be conducted prior to and after nebulizer treatments to ensure effectiveness, and that nebulizer equipment should be changed weekly. The facility's own policy, as provided by the Director of Nursing, also outlined these requirements. These deficiencies were identified through observation, interview, and record review for one of three residents reviewed for respiratory care.