F0695

D

Failure to Perform and Document Required Respiratory Assessments for Nebulizer Treatments

Oshkosh, Wisconsin Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

Staff failed to provide and document required respiratory assessments in connection with nebulizer treatments for one resident. The facility’s Respiratory policy dated 1/2025 requires qualified nursing staff to assess a resident’s pulse, oxygen saturation, and lung sounds prior to nebulizer administration, and to reassess pulse, oxygen saturation, minutes of nebulizer use, and lung sounds after administration, with all respiratory nursing documentation to include pre- and post-nebulizer treatment assessments. The resident involved had physician orders to self-administer nebulizers and an inhaler after nurse set-up three times daily, and a specific order to assess prior to administering nebulizer treatment and to document lung sounds, pulse, and respirations every six hours for COPD. The Medication Administration Record (MAR) showed that all nebulizer treatments were provided, but the ordered nebulizer assessments were not completed as required.

The resident was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, acute pulmonary edema, and heart failure, and had a BIMS score of 13/15, indicating intact cognition, with an activated POA for healthcare. Despite the resident’s respiratory conditions and the clear policy and physician orders, staff did not assess the resident’s lungs prior to set-up or after the self-administered nebulizer treatments, and these assessments were not consistently documented in the MAR. During interview, the DON confirmed that nebulizer assessments should be documented in the MAR and verified that the resident’s nebulizer assessments were not consistently documented, confirming the failure to follow the facility’s respiratory policy and the physician’s orders for respiratory assessment and documentation.