The November 18 incident at Complete Care at Margate Park involved a cognitively intact resident with chronic obstructive pulmonary disease who takes Symbicort twice daily. His physician's order specifically states: "Rinse mouth with water and spit back into cup after use."
Licensed Practice Nurse V37 placed the mouthpiece on the resident's mouth, pressed the canister, and instructed him to inhale the Budesonide/Formoterol medication. After he inhaled two puffs, she told him to drink water.
She should have told him to swish and spit.
Four minutes later, when an inspector asked what should happen after the resident inhaled the medication, V37 acknowledged her error. She stated she should have instructed him to swish and spit water to prevent fungal infection.
The resident, identified as R16 in inspection documents, told inspectors that nurses usually asked him to swish and spit after taking his liquid protein supplement. He said he didn't know why.
Unit Manager V14 explained the next day that nurses are expected to instruct residents to swish and spit water after using inhalers because the medication can cause oral thrush. The resident's medical record shows he has a history of candidiasis, making the oversight particularly concerning.
The facility's own policy manual reinforces the importance of mouth rinsing. A September 2024 document states it is facility policy to ensure medications are administered as prescribed, and specifically requires that residents using corticosteroids "rinse and gargle with water to remove medication from mouth and back of throat."
An November 18 training document found during the inspection explains the rationale: "Why do we have residents rinse their mouth and speak after using a corticosteroid inhaler? To prevent the patient from contracting thrush, a fungal infection of the tongue."
The resident's admission record documents multiple conditions including COPD, Type 2 diabetes, and a history of candidiasis. His mental status assessment scored 15 out of 15, indicating he is cognitively intact and capable of following mouth-rinsing instructions.
The physician's October 9 order for the Symbicort inhaler explicitly addresses his chronic obstructive pulmonary disease and pulmonary fibrosis. The order concludes with clear post-medication instructions that were ignored during the observed administration.
Corticosteroid inhalers like Symbicort work by reducing inflammation in the airways, but residual medication in the mouth and throat creates an environment where fungal infections can flourish. The simple act of rinsing and spitting removes this medication residue.
Federal inspectors documented this as a medication administration failure that placed the resident at risk. The violation affected one resident out of five reviewed for medication administration practices.
The incident occurred during a complaint inspection at the 60640 North Kenmore facility. Inspectors observed the medication error in real time, then interviewed both the nurse and resident about standard procedures.
The resident's confusion about the purpose of mouth rinsing suggests inconsistent education about his medication routine. While he understood that nurses sometimes asked him to swish and spit after his protein supplement, he had not connected this practice to infection prevention.
The nursing staff's immediate acknowledgment of the error indicates awareness of proper procedure, making the oversight more troubling. V37 knew what she should have done but failed to follow through during actual medication administration.
For residents like R16, who already have compromised respiratory systems and diabetes, developing oral thrush could complicate their existing medical conditions. The fungal infection can make eating difficult and potentially spread to other parts of the body in immunocompromised patients.
The facility's detailed policies show management understands the risks associated with corticosteroid inhalers. The gap between written procedures and bedside practice represents a failure in medication safety that could have been prevented with proper attention to physician orders.
Complete Care at Margate Park must now develop a plan of correction to address this medication administration deficiency and prevent similar incidents with other residents who rely on corticosteroid inhalers for their breathing conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Margate Park from 2025-11-20 including all violations, facility responses, and corrective action plans.
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