Failure to Ensure Clinically Appropriate Self-Administration of Inhaler
Penalty
Summary
The facility failed to ensure that self-administration of medication was clinically appropriate for a resident with vascular dementia and asthma. The resident, who had a moderate cognitive impairment as indicated by a BIMS score of 12, was observed self-administering a Budesonide/Formoterol Fumarate inhaler. During the observation, the resident took three puffs in quick succession without holding their breath between puffs, contrary to the prescribed two puffs and proper inhaler technique. The LPN present did not ensure the resident rinsed their mouth after administration, as recommended for this medication. Review of the resident's assessments revealed that the most recent Medication Self-Administration Safety Screen indicated the resident was unable to correctly read medication labels, state the purpose, timing, or dosage of medications, or administer inhalant medications according to proper procedure. An additional assessment scored the resident low on cognitive skills, requiring one-step prompting and encouragement, and showed the resident was unable to identify or understand possible side effects of their medications. There was no documentation that the resident had been observed using the inhaler correctly, nor was there a list of medications the resident was clinically cleared to self-administer.