Failure to Timely Reorder and Administer Asthma Medication
Penalty
Summary
The facility failed to ensure that a routine breathing medication was reordered and received in a timely manner for a resident with a diagnosis of Seizure and Asthma. On March 12, a Licensed Practical Nurse (LPN) confirmed that the inhaler for asthma was not available for Resident #48 at the prescribed time. The LPN initially stated that the inhaler was reordered on March 10, but documentation revealed that the reorder actually occurred on March 12, with delivery on March 13. The March Medication Administration Record confirmed the inhaler had not been administered, and a progress note indicated that the physician was contacted and ordered the medication to be administered once received. Resident #48, who was admitted with diagnoses including Seizure and Asthma, expressed that the facility occasionally runs out of medication. The resident's Care Plan included interventions to give medications as ordered and monitor for side effects and effectiveness. During an interview, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged the concern, with the ADON presenting the inhaler to the surveyor. The DON explained that inhalers should be reordered before they run out, depending on the type of inhaler, and referenced a policy on medication ordering and receiving that emphasized timely receipt from the pharmacy.
Plan Of Correction
1. What corrective action will be accomplished? Resident #48 received ordered inhaler @ 5:59pm on Resident #48 was assessed by ARNP and found to have no adverse effect related to delayed administration of inhaler. The licensed nurses caring for resident #48 were re-educated on the facility policy for re-ordering medication. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: An audit was conducted of current residents who have physicians order/receives inhalers to ensure all are stocked and re-ordered timely. 3. Measures/systematic changes put into place: The licensed nurses were re-educated by the DON/Designee on the facility policy for re-ordering medications (including inhalers). Re-ordering medication (including inhalers) was added to new nurse hire orientation and annual education. 4. How Corrective action will be monitored: The DON/Designee will conduct a daily audit (for 5 weeks) of residents with a physician order for inhalers to ensure the inhaler is available and re-ordered timely. The results of this audit will be reviewed at the monthly QA meeting until compliance has been determined.