Failure to Ensure Proper Mouth Rinse After Steroid Inhaler Administration
Penalty
Summary
Staff failed to implement manufacturer-directed steps to prevent post-administration complications for a resident receiving a steroid-infused inhaler. During a medication administration observation, a trained medication aide provided a resident with a mometasone furoate (Asmanex) inhaler, which was clearly labeled with instructions to rinse the mouth thoroughly after each use. The aide administered the inhaler but did not offer or assist the resident with a mouth rinse before proceeding to give oral medications. The omission was only identified when the surveyor intervened and questioned the aide, who then acknowledged forgetting the step and subsequently assisted the resident with rinsing. The resident involved had moderate cognitive impairment and a history of pneumonia and asthma, as documented in their quarterly MDS. Interviews with the DON and consulting pharmacist confirmed that a mouth rinse should be completed after using an inhaled corticosteroid to prevent oral thrush, and that such instructions should be visible on the MAR for staff reference. The facility did not provide a policy on metered-dose or steroid-infused inhaler use, and there was no evidence of recent staff education or audits regarding proper inhaler administration procedures.