Failure to Assess and Document Respiratory Status After Nebulizer Treatments
Penalty
Summary
The facility failed to properly assess and document a resident's vital signs and lung sounds after administering routine nebulizer breathing treatments. The resident in question had multiple diagnoses, including hypertension, atherosclerotic heart disease, COPD, and a history of stroke. The care plan for this resident included interventions such as administering bronchodilators as ordered, monitoring effectiveness, and keeping the head of the bed elevated. Despite these interventions, the Medication Administration Record (MAR) for October did not include documentation of respiratory assessments or vital signs after the administration of the prescribed nebulizer treatments. Physician orders specified that the resident was to receive both scheduled nebulizer treatments and as-needed (PRN) inhaler treatments for symptoms such as wheezing and shortness of breath. While the effectiveness of a PRN inhaler dose was documented, there was no evidence that respiratory assessments or vital signs were recorded after routine nebulizer treatments. Interviews with the Director of Nursing (DON) confirmed that staff were expected to conduct respiratory assessments after all nebulizer treatments, but this was not consistently done. The resident's representative also noted that the breathing treatments and inhaler were no longer effective for the resident. Further review of facility policy revealed that staff were required to obtain vital signs and perform respiratory assessments before and after nebulizer treatments, and to document these findings in the medical record. The lack of documentation and assessment following the administration of respiratory treatments constituted a failure to follow both physician orders and facility policy, as well as accepted standards of practice for monitoring residents receiving respiratory care.