Respiratory Treatments Administered Without Physician Order or Documentation
Penalty
Summary
A deficiency occurred when a resident with diagnoses including pneumonia, acute respiratory failure, congestive heart failure, and nicotine dependence received respiratory breathing treatments without a written physician order. The facility's policies require that all medications and treatments, including respiratory therapy, be administered only upon the order of a physician or physician extender and that such orders be documented in the medical record. Despite these policies, the resident received at least two respiratory treatments, as confirmed by both the resident and nursing staff, without any corresponding physician order or documentation in the medication administration record (MAR). Interviews with nursing staff, including an LPN and an RN, confirmed that the treatments were administered without a physician order and without documentation of assessments such as lung sounds or vital signs before and after the treatments. The Director of Nursing also acknowledged that the treatments were given without proper orders or documentation. The nurse practitioner later assessed the resident and provided an order for respiratory treatments, but this was after the treatments had already been administered without authorization or record.