Failure to Care Plan Nebulizer Use for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing all of a resident's needs, specifically omitting the care planning for the use of a nebulizer device for one resident. The resident, a female with quadriplegia requiring total assistance for activities of daily living and with an intact cognitive status, had a physician order for Ipratropium-Albuterol via nebulizer as needed for shortness of breath or wheezing. Despite the physician order being present in the resident's records, the comprehensive care plan did not include any information or interventions related to the nebulizer use. Observations confirmed the resident was using a nebulizer, and interviews with nursing staff, including the RN, ADON, MDS nurse, and DON, revealed that the omission was due to a lack of communication and failure to update the care plan when the physician order was received. Staff acknowledged that the care plan should have been updated to reflect the new order, and that the interdisciplinary team is responsible for ensuring care plans are comprehensive and current. The facility's policy requires care plans to be reviewed and revised as needed, but this was not followed in this instance.