F0695

E

Failure to Provide Ordered Respiratory Medications and Accurate MAR Documentation

Monroeville, Pennsylvania Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The facility failed to provide safe and appropriate respiratory care and medication administration for two residents with COPD and other cardiac conditions. Facility policy required medications to be administered safely, timely, as prescribed, and fully documented, including date, time, dosage, route, and results. For one resident with atrial fibrillation and COPD, the MDS showed a BIMS score of 15, indicating cognitive intactness. Physician orders dated 1/20/26 directed that this resident receive Breo Ellipta once daily, with a documented therapeutic interchange to Ipratropium‑Albuterol nebulizer solution every eight hours. Review of the MAR from 2/1/26 through 2/24/26 showed multiple days when Breo Ellipta was marked as received, some days marked as held, and one day undocumented, but there was no documentation of the timing or administration of the substituted Ipratropium‑Albuterol nebulizer treatments. The resident confirmed he had not been receiving his Breo Ellipta inhaler.

A second resident, admitted with diagnoses including coronary artery disease and COPD and a BIMS score of 14, had a plan of care for shortness of breath related to Flu A and COPD that did not include the use of respiratory medications or nebulizer treatments. Physician orders dated 1/30/26 directed that this resident receive Trelegy Ellipta once daily and Ipratropium‑Albuterol inhalation aerosol every six hours as needed for COPD, with a pharmacy‑supplied therapeutic interchange to Ipratropium‑Albuterol nebulizer solution every six hours as needed. Review of the MAR from 2/1/26 through 2/24/26 showed Trelegy Ellipta documented as received on most days, with several days marked as held and one day undocumented. Despite these MAR entries, the resident later confirmed he had not been receiving his Trelegy Ellipta inhaler.

On observation of the medication cart on the 100‑unit hall, neither resident’s Breo Ellipta nor Trelegy Ellipta inhalers were present. Instead, unopened pharmacy‑supplied boxes of Ipratropium‑Albuterol nebulizer ampules labeled as therapeutic interchange were found, with full supplies and no ampules removed. An LPN confirmed that the inhalers were not in the cart and that no Ipratropium‑Albuterol ampules had been used, yet could not explain why the MAR reflected that both residents had received their inhalers during the morning medication pass. Later observation in the shared room showed both residents receiving nebulizer treatments, and interviews at that time confirmed that neither resident had previously received nebulizer treatments in the facility. The nursing home administrator and DON acknowledged that the facility failed to provide appropriate respiratory care for these two residents.