Failure to Perform and Document Required Assessments for Nebulizer Treatments
Penalty
Summary
The facility failed to ensure required respiratory assessments and equipment care were provided and documented for a resident receiving nebulizer treatments. Resident B, who had diagnoses including COPD and emphysema, had a physician’s order dated 2/6/26 for Yupelri 175 mcg, 3 ml once daily via nebulizer at 9:00 a.m. for 20 days. Observation on 2/23/26 showed the resident with a nebulizer machine at the bedside. Review of the February 2026 MAR indicated the resident received 16 doses of Yupelri between 2/6/26 and 2/23/26. The clinical record lacked documentation of pre- and post-treatment respiratory assessments and cleaning of the nebulizer equipment after each administration. Facility policy titled “Nebulizer Treatments,” provided by the Regional Director of Clinical Operations, required collection of respirations, pulse, oxygen saturation, and lung sounds before treatment, repetition of this data collection after treatment, and rinsing the nebulizer with sterile water and allowing it to air dry. In an interview, an RN confirmed that a respiratory assessment should be completed before and after each nebulizer treatment, but such assessments and equipment cleaning were not documented for this resident’s treatments.
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