Failure to Rinse Mouth After Symbicort Administration
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, specifically during the administration of medication. On March 6, 2025, during a medication pass observation, a Licensed Practical Nurse (LPN) did not rinse the mouth of a resident after administering a Symbicort inhaler, which is a steroid medication. This omission was contrary to the physician's orders and the facility's medication administration policy, which requires rinsing the mouth to prevent oral fungal infections. The resident, who was cognitively intact, had a diagnosis of Chronic Obstructive Pulmonary Disease and was prescribed Symbicort to be administered twice daily with a directive to rinse the mouth after use. The LPN admitted to being nervous, which led to the oversight. Interviews with the Registered Nurse Educator and the Director of Nursing Services confirmed that the mouth rinse was a necessary step to prevent potential side effects such as oral thrush. The facility's policy clearly outlined the responsibilities of licensed nurses to be aware of medication administration standards, including the need to rinse the mouth after administering steroidal inhalation medications.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. The following actions were accomplished for the residents identified in the sample: Upon notification from the NYS Surveyor that the Licensed Practical Nurse (LPN) failed to rinse resident # 260’s mouth, as per the physician order, the LPN immediately rinsed resident # 260’s mouth as ordered. Resident # 260 was seen and examined by the attending physician (MD) on 3/10/2025 at 1:22 pm. The MD documented that there was no evidence of thrush or oral plaques noted. In addition, beginning on 3/10/2025, the nurse who was observed, as well as all other medication administration nurses, were re-educated regarding the need to rinse resident’s mouths after administering steroid inhalation medications. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents who have an order for [REDACTED]. The facility’s Director of Pharmacy (DOP) will generate a list of all residents who have active orders for all inhalation type of medications by 03/28/2025. The DOP will indicate which of these residents have an inhalation medication that is in the steroidal drug class. Beginning on (MONTH) 31, 2025, the Nursing Informatics Coordinator will review all MD orders for steroidal inhalers to ensure that the order includes directives to rinse the resident’s mouth after administration. Beginning on (MONTH) 1, 2025, the Nursing Educators will conduct medication administration competencies on all facility nurses who are administering steroidal medications to residents to ensure that they are following physician orders, and rinsing the residents mouths after administration. III. The following system changes will be implemented to ensure continuing compliance with the regulations, and that the same deficient practice does not recur: The Interdisciplinary Team (IDT) reviewed the policy and procedure titled “Medication Administration” on 03/20/2025. There were no necessary changes to the Policy and Procedure upon review. The policy and procedure titled “Medication Administration” was further reviewed by the Director of Nursing, Medical Director and Facility Administrator on 03/24/2025 and approved on 03/24/2025. Beginning on (MONTH) 7, 2025, the Nursing Educators will conduct re-education sessions regarding aspects of medication administration to all facility licensed nursing staff (RN and LPN). The education will include, at minimum, the rights of medication administration, reviewing the MD orders prior to administering medications, a brief review of different types of drug classifications and the importance of rinsing residents mouths after administering steroidal inhalation medications. This education will be completed by (MONTH) 2, 2025. IV. The facility’s compliance will be monitored using the following quality assurance system: Effective (MONTH) 2025, under the direction of the Quality Assurance and Performance Coordinator (QAPI) the facility developed an audit tool to ensure that nurses administering steroidal inhalation medications are correctly following MD orders to rinse residents mouths after administering the medication. Each month the pharmacist will generate a list of residents who are currently receiving a steroidal inhalation medication. These residents will be added to the developed audit tool to ensure compliance. The Nurse Educators, or designees, will complete a competency assessment on all licensed nurses responsible for medication administration on a monthly basis, based on the list of residents identified by the pharmacist. Deficient practices will be corrected immediately, and nurses who fail to adhere to the MD orders for steroidal inhalation medication will be directed to the nursing education classroom for formal re-education and competency before they are permitted to administer any type of medication to facility residents. These audits will be completed monthly for three (3) months and quarterly for three (3) consecutive quarters, and will be conducted across all shifts. All audit findings will be reported to the facility Administrator and Director of Nursing (DON) following completion. The DON will report results of the audits at the facility’s quality assurance and performance improvement committee meeting. The compliance standard will be set to 100%. At the end of the third quarter, the QAPI committee will meet to review the results of the completed audits and discuss the need for further audits and at which frequency. Corrective action will be implemented as needed after the QAPI review of the audits. Responsibility: Director of Nursing