Unauthorized Repeat Administration of Nebulizer Treatment Without Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to administer medications according to physician orders for one resident. The resident had diagnoses including chronic systolic congestive heart failure, acute kidney failure, and traumatic subarachnoid hemorrhage, and had an intact cognition score of 15/15 on the Brief Interview for Mental Status. A physician’s order dated 2/17/26 directed that Albuterol Sulfate Inhalation Nebulization (2.5 mg/3 mL 0.083%) be given as one vial via nebulizer one time only for shortness of breath for one day. The February 2026 medication administration record showed that this nebulizer treatment was administered on 2/17/25 in accordance with the order. However, a nursing progress note dated 2/18/2026 at 20:03 documented that the resident was found sitting in a chair with pants off and experiencing some shortness of breath, and that the writer (nurse) administered a breathing treatment and explained to the resident that the doctor had started them on a new medication, prednisone, to help reduce shortness of breath and help their lungs. The note further documented that the resident tolerated the medications well, could make needs known, was continent of bowel and bladder, and had vital signs recorded. There was no physician order for an additional breathing treatment beyond the original one-time-only nebulizer order, and the DON confirmed that the order was for one time only and should not have been given again without a physician’s order. The facility’s Medication Orders Policy stated that medications are to be administered only upon the clear, complete, and signed order of an authorized prescriber.
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