Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to assess and obtain a physician's order for a resident to self-administer medication and keep it at the bedside. The resident, who had diagnoses including chronic obstructive pulmonary disease and malignant neoplasm of the lungs, was observed with an albuterol sulfate inhaler on the bedside table, which he used as needed without staff reminders. The resident's cognitive abilities were intact, and he had been keeping the inhaler at his bedside for about a week. However, there was no staff present during the observation, and the resident's care plan did not indicate permission to keep the inhaler at the bedside. The Director of Nursing confirmed that the facility's policy required an assessment by the interdisciplinary team and a physician's order for a resident to self-administer medications. Despite this, the resident's electronic medical record lacked an assessment for self-administration or bedside storage of medications. The nurse responsible for the resident was unaware of the self-administration, and the resident's order summary indicated the inhaler was scheduled for use four times a day, not as needed. The facility contacted the resident's Nurse Practitioner to obtain the necessary order only after the surveyor's observation.