Incomplete Respiratory Assessment Prior to Inhaler Administration
Penalty
Summary
A deficiency occurred when a respiratory therapist (RT) failed to provide a complete respiratory assessment prior to administering a prescribed albuterol inhaler to a resident with interstitial pulmonary disease and congestive heart failure. The RT only auscultated the top left and right lobes of the resident's chest from the front, neglecting to assess the back or the remaining lobes. The resident's medical record indicated a moderate cognitive impairment and a history of cardiorespiratory conditions. The RT did not assess the resident for pain at the time of medication administration. During interviews, the RT acknowledged that the standard practice was to listen to all lung lobes and admitted to being trained to do so, but did not follow this protocol. A registered nurse confirmed that the expectation was to assess all lobes before administering respiratory medication. Review of facility policies revealed no specific guidance on respiratory assessment, and the competency checklist required auscultation of breath sounds as part of the assessment. The facility did not have a policy specifically addressing respiratory assessment.