Failure to Administer Prescribed Inhaler and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with a history of asthma, acute cough, and recent COVID-19 infection did not receive their prescribed Atrovent HFA inhaler as ordered by the physician. The medication was not administered on one evening and three subsequent scheduled times the following day because the inhaler could not be located after the 5:00 PM dose. According to facility policy, if a medication is unavailable at the prescribed time, the practitioner must be notified and new orders obtained. However, the physician was not notified immediately when the medication was found to be missing, and no substitute medication was ordered at that time. Interviews revealed that nursing staff were aware of the missing inhaler and reported it to the nursing supervisor, but the physician was not contacted until the following day after the resident's family raised concerns. The physician confirmed that they expected to be notified if a medication could not be administered, and would have provided an alternative order if contacted. The delay in communication and failure to follow policy resulted in the resident missing multiple doses of a prescribed bronchodilator.