Failure to Administer Prescribed Respiratory Medications
Penalty
Summary
Licensed nurses failed to administer prescribed respiratory medications to a resident with chronic obstructive pulmonary disease (COPD), emphysema, respiratory failure with hypoxia, recurrent pneumonia, and vascular dementia. The resident was oxygen-dependent and required staff assistance for all activities of daily living. The care plan specifically included interventions to administer medications as ordered for impaired gas exchange and ineffective airway clearance. A review of the Medication Administration Records (MAR) for three months revealed that multiple scheduled doses of three critical respiratory medications—Acetylcysteine Inhalation Solution, Budesonide Inhalation Suspension, and Ipratropium-Albuterol Inhalation Solution—were not documented as administered. Specifically, there were 25 undocumented doses of Acetylcysteine, 31 undocumented doses of Budesonide, and 60 undocumented doses of Ipratropium-Albuterol. Physician progress notes during this period consistently indicated the need to continue regular breathing treatments as scheduled, and nursing notes documented episodes of shortness of breath and diminished lung sounds. During interviews, the Director of Nursing confirmed the absence of documentation for the administration of these medications and acknowledged that the resident did not receive them as ordered. The attending physician also confirmed that missing several doses of these medications, especially consecutively, could trigger a COPD exacerbation. Facility policy required medications to be administered in accordance with prescriber orders, but this was not followed in this case.