Failure to Ensure Proper Administration of Inhalation Medication
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow physician orders and manufacturer guidelines during the administration of Budesonide, an inhalation medication, to a female resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident, who had intact cognition and was able to communicate clearly, had a physician order specifying that she should rinse and spit after each use of Budesonide via nebulization. During a medication pass, the LVN administered the medication but only provided a glass of water afterward, without instructing the resident to rinse and spit as required. Interviews with the LVN, Director of Nursing (DON), and Administrator confirmed that the medication should have been administered according to the physician's order and that special instructions, such as rinsing and spitting, were necessary to prevent adverse effects. The facility's medication administration policy also required medications to be given per orders and manufacturer guidelines. The failure to follow these instructions was observed and acknowledged by staff, constituting a deficiency in pharmaceutical services for the resident.