F0695

D

Failure to Document Respiratory Assessments for Nebulizer Treatments

Demotte, Indiana Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The facility failed to provide safe and appropriate respiratory care by not documenting a respiratory assessment when a resident experienced a change in condition and by not completing required pre- and post-nebulizer assessments. The resident had multiple diagnoses including COPD, heart failure, hypertension, dementia, atrial fibrillation, and depression, and was receiving oxygen therapy. A quarterly MDS indicated the resident was cognitively impaired. On one date, a progress note documented that the resident appeared to sleep well but staff noticed a cough, with lungs described as clear. Later that same day, a physician’s order was obtained to start albuterol sulfate nebulizer treatments twice daily for cough for a specified period, and the MAR showed the medication was administered as ordered.

Despite the initiation and ongoing administration of nebulizer treatments, the clinical record lacked documentation of the respiratory assessment that led to the new breathing treatment order, as well as any pre- and post-respiratory assessments for each nebulizer treatment. In an interview, an LPN stated that a CNA had reported the resident’s cough, that she performed a respiratory assessment, and then contacted the physician who ordered the nebulizer, but she acknowledged she did not document her assessment and that pre- and post-assessments should have been completed. The DON confirmed that the nurse should have documented the respiratory assessment supporting the start of nebulizer therapy and that staff should have completed and documented pre- and post-assessments with each treatment, but she was unable to find any such documentation. The facility’s nebulizer policy required obtaining vital signs and performing respiratory assessments to establish a baseline.