Failure to Document Respiratory Assessment and Obtain Oxygen Order
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a history of influenza and Parkinson's disease. Specifically, staff did not monitor or document a respiratory assessment after administering a nebulizer treatment, as required by facility policy. The policy mandates documentation of vital signs, including oxygen saturation before and after treatment, as well as the resident's tolerance to the treatment. Record review showed that the LPN documented the administration of the nebulizer treatment but did not record the required post-treatment respiratory assessment or vital signs in the Medication Administration Record (MAR). Additionally, the facility failed to obtain a physician's order for the administration of oxygen therapy to the resident. Observations revealed the resident was receiving oxygen via nasal cannula and using a portable oxygen tank, but there was no documented order for this therapy. Staff interviews confirmed that the oxygen was applied after a low oxygen saturation reading was reported, but the necessary physician authorization was not present in the resident's records.