Failure to Ensure Mouth Rinsing After Steroid Inhaler Administration
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident with chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD), and type 2 diabetes rinsed her mouth after administration of the Trelegy Ellipta inhaler, as required by the physician's order and the manufacturer's prescribing information. The resident was cognitively intact and self-administered the inhaler, but staff did not supervise or remind her to rinse her mouth following use, which is necessary to prevent oral infections such as thrush due to the corticosteroid component in the medication. Observation confirmed that the resident was given the inhaler without being prompted or assisted to rinse her mouth afterward. Interviews with staff, including medication aides, the pharmacist, LPN, DON, and the administrator, revealed an understanding of the importance of mouth rinsing after steroid inhaler use, but also acknowledged that the required step was missed during the observed administration. Facility policy and the manufacturer's instructions both specify that medications should be administered as ordered and according to professional standards, including rinsing the mouth after inhaler use.