Failure to Document Required Respiratory Assessments for Nebulizer Treatments
Penalty
Summary
The facility failed to ensure that respiratory assessments were conducted and documented for residents receiving nebulizer treatments. Specifically, three residents with diagnoses such as chronic respiratory failure, chronic obstructive pulmonary disease, dyspnea, and wheezing were ordered to receive nebulized medications including Budesonide and Ipratropium-Albuterol. However, their clinical records did not contain documentation of respiratory assessments before, during, or after the administration of these medications, as required by facility policy and physician orders. Staff interviews confirmed that respiratory assessments, including pulse, respiratory rate, and lung sounds, should be obtained and documented prior to, during, and after nebulizer treatments to monitor effectiveness and resident response. The facility's own procedure for administering medications via nebulizer also outlined these assessment requirements. Despite this, the records for the affected residents lacked evidence that these assessments were performed or recorded at the required times.