Missed COPD Inhaler Doses Due to Misplaced Medication
Penalty
Summary
The facility failed to provide ordered pharmaceutical services when a resident with chronic obstructive pulmonary disease (COPD), whose principal diagnosis was COPD, did not receive two scheduled doses of an ipratropium-albuterol inhaler. The resident’s medication review showed an order for the inhaler to be administered four times daily for COPD, and the August medication administration record documented that the 3:00 PM and 8:00 PM doses on 8/18/25 were not given, with a code directing to progress notes. The corresponding progress notes stated the medication was not available for those doses. The resident reported missing two doses of the inhaler about a week prior and did not know why. A nurse stated that when she attempted to administer the inhaler at the scheduled time, it was not in the medication cart, resulting in the missed doses, and that the inhaler was later found at the end of the resident’s bed, although it should have been stored in the medication cart. The DON confirmed the inhaler had been misplaced and should have been kept in the medication cart, and the resident’s care plan and the facility’s medication administration policy both required that medications be administered as ordered.
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