Federal inspectors found the facility failed to develop required care plans for respiratory treatments despite having residents with conditions including pneumonia, respiratory failure, and heart failure who needed regular breathing assistance.
The first resident, identified as R10, had been diagnosed with pneumonia and respiratory failure according to her December 2024 assessment. Her physician had ordered two different nebulizer medications: budesonide for shortness of breath and wheezing every 12 hours as needed, and a combination of ipratropium and albuterol four times daily as needed for the same symptoms.
R10's care plan, last updated in August 2024, acknowledged she had potential for impaired gas exchange related to congestive heart failure and noted she received oxygen therapy as needed for shortness of breath. But inspectors found no care plan addressing her nebulizer treatments.
The second resident, R13, faced similar gaps in planning. His November 2024 assessment showed diagnoses of anemia, coronary artery disease, and heart failure. His physician had ordered albuterol nebulizer treatments every six hours as needed.
Like R10, R13's care plan from August 2024 recognized his risk for impaired gas exchange related to episodes of shortness of breath and mentioned oxygen therapy as needed. Yet no care plan existed for his nebulizer therapy.
The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables for each resident. The policy specifically mandated that care plans describe all services needed to maintain residents' highest practicable physical, mental and psychosocial well-being.
When inspectors interviewed the unit nurse on February 19, she confirmed R10 lacked a care plan for nebulizer therapy. She told inspectors she was unaware the care plans had not been developed.
The Director of Nursing acknowledged the missing care plans during a February 20 interview. She confirmed R10's physician orders for nebulizer treatments as needed and admitted no care plan existed for these treatments. She told inspectors that all care areas, including medications, diagnoses, and treatments, should have care plans.
The inspection revealed a troubling disconnect between what medical assessments documented and what care plans addressed. Both residents' quarterly assessments indicated they received no respiratory treatments, despite physician orders for regular nebulizer medications.
For R10, this gap was particularly concerning given her recent pneumonia and respiratory failure diagnoses. Nebulizer treatments deliver medication directly to the lungs and airways, making proper administration and monitoring critical for residents with breathing difficulties.
R13's situation highlighted similar risks. His heart conditions could complicate respiratory issues, making coordinated care planning essential for managing both his cardiac and breathing needs effectively.
The missing care plans left staff without clear guidance on when to administer treatments, how to monitor effectiveness, or what signs might indicate the need for adjustments. Without written protocols, residents faced potential delays in receiving prescribed medications or inadequate monitoring of their respiratory status.
Federal regulations require nursing homes to develop comprehensive care plans that address all aspects of resident care, including medical treatments. These plans serve as roadmaps for staff, ensuring consistent care delivery and proper monitoring of treatment effectiveness.
The inspection found the facility had policies in place requiring such comprehensive planning but failed to implement them for these respiratory treatments. This represents a breakdown in the facility's care planning process that could affect other residents receiving specialized treatments.
Both residents continued to live with their respiratory conditions while receiving treatments that lacked proper care coordination. The absence of written care plans meant their complex medical needs were not being addressed through the systematic approach required by federal standards.
The deficiency placed residents at risk for medical complications that could arise from inconsistent treatment administration or inadequate monitoring of their respiratory status. Without proper care plans, staff lacked clear protocols for managing these residents' breathing difficulties effectively.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hill Haven Nursing Home from 2025-02-20 including all violations, facility responses, and corrective action plans.