Failure to Administer Ordered Albuterol Inhaler for Resident with Respiratory Needs
Penalty
Summary
The facility failed to ensure that a resident received respiratory treatment and care in accordance with professional standards and physician orders. Specifically, the resident, who had diagnoses including Chronic Diastolic Congestive Heart Failure, Essential Hypertension, and COPD, had active orders for Budesonide Inhalation Suspension twice daily and Albuterol Sulfate HFA every four hours as needed for shortness of breath and wheezing. Despite these orders, the resident did not receive her Albuterol inhaler as prescribed on two consecutive days. The resident reported this omission and stated she had been receiving her inhaled medications in a specific sequence for years, with Albuterol administered prior to Budesonide, which she found effective for her symptoms. The failure occurred when the assigned LPN was uncomfortable administering the medications in the requested sequence and, after consulting with the on-call nurse and the DON, was advised to withhold the Albuterol if uncomfortable. No clinical assessment, provider consultation, or documentation of clinical justification for withholding the medication was completed. The DON acknowledged that the medication was not administered as ordered and that the provider should have been contacted for clarification if there was uncertainty. The nurse practitioner later confirmed that the orders were to be followed as written.