Ordered COPD Inhaler Not Available for Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that prescribed medication was available for a resident. The resident, admitted on 02/17/22, had diagnoses including acute respiratory failure with hypercapnia, acute and chronic respiratory failure with hypoxia, COPD, acute on chronic diastolic congestive heart failure, chronic kidney disease stage three, and dysphagia. A quarterly MDS dated 01/23/26 documented that the resident had intact cognition, was dependent on staff for ADLs and eating, used a motorized wheelchair, required a mechanical lift for transfers, and was frequently incontinent of bowel and bladder. The plan of care dated 12/01/25 indicated the resident required continuous oxygen related to acute respiratory failure, COPD, pneumonia, and shortness of breath while lying flat, with interventions including administering oxygen at 2 L/min, educating the resident on oxygen use and settings, maintaining the head of bed elevated, and reporting signs of hypoxia. Review of physician’s orders for February 2026 showed that on 02/05/26 the resident had an order for Fluticasone Furoate-Vilanterol Inhalation Aerosol Powder Breath Activated 100-25 mcg per actuation, one puff inhaled orally once daily for COPD. During observation of medication administration on 02/17/26 at 9:41 A.M., surveyors found that the facility did not have the resident’s ordered Fluticasone Furoate-Vilanterol inhaler available. An interview with an LPN confirmed that the inhaler was not available for the resident. Facility policy titled “Administering Medications” dated 04/2019 stated that medications are to be administered in accordance with prescriber orders, including any required time frame. The lack of availability of the ordered inhaler constituted non-compliance with this policy and with the requirement to provide pharmaceutical services to meet each resident’s needs.
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