Failure to Reassess and Discontinue Unnecessary Scheduled Bronchodilator Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications by not evaluating the continued need for a bronchodilator prescribed for wheezing. A resident with dementia, pleural effusion, and CHF was started on scheduled ipratropium bromide/albuterol nebulizer treatments every four hours after a nurse reported wheezing to the PA, who also ordered a chest x-ray. The chest x-ray later showed no acute findings, and subsequent clinical assessments by the Medical Director and PA over the following months consistently documented that the resident denied chest pain and shortness of breath, had even and unlabored respirations, and had lungs clear to auscultation without wheeze. Despite this, the MAR showed the bronchodilator continued to be administered as ordered, except when refused, through late February. During observation, the resident was noted in bed without wheeze or shortness of breath, with a nebulizer machine at the foot of the bed. The support nurse responsible for the resident stated she was unsure why the bronchodilator was still being given, as she had not observed wheezing and staff had not reported ongoing symptoms to support its use. The consultant pharmacist reported she reviewed the resident’s medications monthly but did not address the bronchodilator with the provider because the PA’s visit notes indicated continuation of the current treatment plan. The PA later stated the medication should have been ordered PRN for occasional wheeze, that she had not observed wheezing or been informed of it, and that she was unaware the medication continued to be administered on a scheduled basis. The DON acknowledged the order should have been written as PRN initially and that nursing staff should have recognized the absence of symptoms and contacted the provider to change or discontinue the order, and also noted there was no process in place to review older standing orders during clinical meetings.
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