Failure to Prompt Mouth Rinsing After Steroid Inhaler Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident rinsed his mouth after using a steroid inhaler, as required by manufacturer guidelines and facility policy. Resident #218, admitted on 07/28/25 with diagnoses including schizoaffective disorder, depressive type, and chronic obstructive pulmonary disease, had an MDS assessment indicating intact cognition. During a medication pass observed on 02/26/26 at 8:44 A.M., LPN #584 handed Resident #218 a BREO steroid inhaler. The resident took one breath from the inhaler and returned it to the nurse, and the nurse did not encourage or prompt the resident to rinse his mouth afterward. Immediately after the observation, LPN #584 stated that the resident had refused to rinse his mouth in the past, so she did not say anything on this occasion, and she agreed she should have prompted him to rinse. Later, the Regional Director of Clinical Operations confirmed that staff should be encouraging residents to rinse their mouths after using a steroid inhaler. Review of the BREO inhaler guidelines from accessdata.fda.gov indicated that after inhalation, the resident should rinse the mouth with water without swallowing to help reduce the risk of overgrowth of yeast in the mouth (oropharyngeal candidiasis). Review of the facility’s undated Medication Administration policy also noted that residents were to rinse their mouths after using a steroid inhaler. This incident was identified as an incidental finding during a complaint investigation.
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