Failure to Provide Ordered Inhaler Medication to Resident
Penalty
Summary
A resident with a history of COPD, chronic respiratory failure, end stage heart failure, and who was receiving hospice services, was admitted with physician's orders for a daily Trelegy Ellipta inhaler, to be self-administered at the bedside. During a medication administration observation, it was found that the resident did not have access to the prescribed inhaler. Staff confirmed that the inhaler had been ordered but had not yet been delivered, and the resident reported not having the medication for approximately two weeks, resulting in increased shortness of breath. Review of the Medication Administration Record showed the medication was marked for unsupervised self-administration, but there was no documentation of any follow-up with the pharmacy or physician regarding the missing medication. The DON was unaware of the issue until notified by pharmacy that the order was cancelled due to authorization and cost approval requirements. There was no evidence that the facility took timely action to ensure the resident received the prescribed medication as ordered.