Incomplete Respiratory Treatment Documentation in Clinical Record
Penalty
Summary
The facility failed to ensure complete and accurate clinical records for a resident with acute respiratory failure with hypoxia and cystic fibrosis with pulmonary manifestations. Review of the resident’s February 2026 Respiratory Administration Record (RAR) showed multiple scheduled respiratory tasks and treatments with no documentation of completion or reason for omission. These included checking emergency equipment at the bedside every shift, continuous pulse oximetry every shift, oxygen via nasal cannula with titration parameters every shift, and rotation of the pulse oximeter probe every shift, all of which had blank entries on several specified dates. The DON confirmed that respiratory care and treatments were to be documented on the RAR and acknowledged the blank spaces on the record. Further review of the same resident’s RAR revealed missing documentation for ordered respiratory treatments scheduled every eight hours, including Albuterol Sulfate nebulizer treatments for shortness of breath, chest percussion for respiratory insufficiency, and HyperSal (7% Sodium Chloride) nebulizer treatments for secretions, with multiple dates left blank. The DON stated uncertainty as to whether the care or treatments were not provided or were provided but not documented, and confirmed that if care or treatment was held or refused, the RAR should indicate this rather than be left blank. The facility’s documentation policy, revised 11/07/2024, required staff to document assessments, interventions, procedures, treatments, outcomes, services provided, and any refusals of medications and/or treatments in the resident’s record.
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