Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R150, was assessed for self-administration of medications before leaving inhalers at her bedside. The facility's policy requires a written order from the attending physician and approval from the Interdisciplinary Care Plan Team for a resident to self-administer or retain medications in their room. However, R150's electronic health record and care plan did not include any assessments or orders for self-administration of medications. Despite this, R150 had two medicated inhalers left at her bedside, which she stated had been there for a month, and she was told by staff that she could administer them on her own. Interviews with facility staff revealed inconsistencies in the understanding and application of the facility's protocol regarding medications at the bedside. A CNA was unsure if there was an order for the inhalers to be left at the bedside, while an LPN incorrectly believed there was an order for R150 to have the inhalers at her bedside due to her respiratory issues. The Director of Nursing confirmed that a physician's order and an assessment of the resident's ability to self-administer were required before medications could be left at the bedside. The lack of proper assessment and authorization for R150 to self-administer her inhalers represents a failure to adhere to the facility's medication administration policy.