Failure to Administer Prescribed Inhalation Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident with chronic obstructive pulmonary disease (COPD) received the prescribed Tyvaso Dry Powder Inhaler (DPI) as ordered by the physician. The resident was admitted with multiple diagnoses, including COPD and acute respiratory failure, and had a care plan that required administration of aerosol or bronchodilators as ordered. Physician orders were in place for Tyvaso DPI at varying dosages over several weeks. However, clinical record review and medication administration records (MAR) revealed multiple missed doses of Tyvaso DPI, with documentation indicating the medication was 'on order' or unavailable, despite the resident's family having provided the medication to the facility and it being stored on site. Staff interviews revealed confusion among nursing staff regarding the source and administration of the medication. An LPN stated that medications were always ordered through the pharmacy and was unaware that the family had supplied the Tyvaso DPI. The Assistant Director of Nursing confirmed that the medication was never ordered through the pharmacy and that the family had brought it in, but due to confusion over titration and dosage, the administration was inconsistent and not all doses were given as ordered. The facility's policy required medications to be administered according to prescriber orders, but this was not followed in this case, resulting in missed doses and a failure to comply with physician instructions.