F0695

D

Failure to Supervise Nebulizer Treatment for Non-Authorized Self-Administering Resident

Anderson, Indiana Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide supervised nebulizer treatments to a resident who had not been authorized to self-administer medications. During an observation, the resident was found lying in bed holding a nebulizer mask to her face with the nebulizer machine running on the bedside table and no staff present. A CNA briefly entered the room to state she would return to provide care, then left, and the nebulizer continued without nursing supervision until the MDS Coordinator entered and turned off the machine. The MDS Coordinator stated she did not know if the resident could self-administer nebulizer treatments and noted the resident’s nurse was on break.

Record review showed the resident had diagnoses including unspecified dementia without behavioral disturbance and a physician’s order for ipratropium-albuterol nebulizer treatments three times daily for COPD, with no order authorizing self-administration of nebulizer treatments. The resident’s progress notes and care plan contained no documentation related to self-administration of nebulization. An RN later stated the resident was not able to self-administer but that he typically allowed her to complete nebulizer treatments without staff present due to other medication priorities. A self-administration assessment, dated with an observation several days earlier but completed on the same day as the survey review, indicated it was appropriate for the resident to self-administer ipratropium-albuterol and store the medication in her room; however, this assessment was not yet reflected in the care plan or progress notes at the time of the observation. Facility policy required staff to remain with a resident during nebulizer treatment unless the resident had been assessed and authorized to self-administer.