Failure to Enter and Document Nebulizer Treatment Orders
Penalty
Summary
Staff failed to follow physician orders for a resident with multiple serious diagnoses, including COPD, asthma, and cardiomegaly, by not entering an order for an albuterol nebulizer treatment into the medical record. The resident experienced several episodes of hypoxia and shortness of breath, with oxygen saturations dropping as low as 77-88%. Despite telehealth providers documenting the need for nebulizer treatments in their encounter notes on two separate occasions, there was no corresponding physician order entered into the resident's medical record, nor was there documentation that the nebulizer treatment was administered. Nursing progress notes indicated ongoing respiratory distress and confusion, with fluctuating oxygen levels and eventual transfer to the hospital. Interviews with facility leadership confirmed that the expected process of entering all treatment orders into the medical record was not followed, and it was unclear whether the resident actually received the prescribed nebulizer treatments. The lack of documentation and order entry created uncertainty about the care provided during the resident's acute respiratory episodes.