Failure to Ensure Resident Rinsed Mouth After Inhaled Medication Administration
Penalty
Summary
Facility staff failed to follow professional standards of care during medication administration for one resident diagnosed with chronic obstructive pulmonary disease (COPD). During a medication pass observation, an LPN administered Breo Ellipta (fluticasone furoate-vilanterol) inhalation powder to the resident, followed by other prescribed oral medications. The LPN did not prompt or request the resident to rinse and spit their mouth after using the inhaler, despite the medication's pharmacy label and manufacturer's instructions clearly stating that rinsing the mouth after each use is necessary to reduce the risk of oropharyngeal candidiasis. Upon inspection of the medication and interview with the LPN, it was confirmed that the LPN did not ask the resident to rinse their mouth, stating that the resident does not cooperate with this instruction. The clinical record included a physician's order for daily use of Breo Ellipta for COPD, and the manufacturer's instructions were available on the medication cart. The deficiency was reviewed with facility administration, and no additional information was provided before the end of the survey.