Failure to Monitor Residents During and After Nebulizer Treatments
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required nebulizer treatments. Observations revealed that both residents were left unattended during and after their breathing treatments, with the nebulizer masks remaining on their faces after the medication had been fully administered. In both cases, no licensed nurse was present at the bedside to monitor the residents for potential complications or to remove the equipment promptly after the treatment was completed. For one resident, who was non-verbal and diagnosed with hypoxia, the nebulizer mask was observed still in place with an empty medication chamber, and the nurse confirmed she had left the room to assist another resident. The nurse acknowledged that facility policy required her to remain with the resident during the treatment and to remove the mask once the medication was finished. Similarly, another resident with chronic respiratory failure and hypoxia was found with the nebulizer mask on and no medication solution remaining, and the nurse admitted to leaving the resident unattended for about an hour after the treatment had ended. Interviews with both nurses and the Director of Nursing confirmed that the expected procedure was to remain with residents during nebulizer treatments, monitor for any signs of distress, and remove the mask promptly after completion. Review of the facility's policy further supported these requirements, specifying that staff should remain with the resident, monitor for side effects, and obtain post-treatment assessments. The failure to follow these procedures resulted in the deficiency cited in the report.