Failure to Ensure Proper Administration of Corticosteroid Inhalers
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy and manufacturer instructions. During 35 observed medication administration opportunities, two medication errors were identified, resulting in a 5.71% error rate. Specifically, during two separate medication passes, nursing staff did not instruct residents to rinse and spit after administering corticosteroid inhalers, despite clear facility policy and manufacturer instructions requiring this step. Both inhaler boxes had bright green notes stating, "Rinse mouth thoroughly after each use," but this directive was not followed during the observed administrations. Interviews with the involved LPNs revealed uncertainty and forgetfulness regarding the requirement to provide water and instruct residents to rinse and spit after inhaler use. The pharmacist confirmed that rinsing the mouth after using inhaled corticosteroids is necessary to prevent oral candidiasis and stated that staff were alerted to this requirement through labeling on the medication packaging. The DON and ADON also acknowledged that mouth rinsing is recommended for steroid inhalers and that staff were expected to encourage this practice, as indicated on the medication packaging.