Failure to Ensure Proper Assessment Before Self-Administration of Medication
Penalty
Summary
A resident with diagnoses including seizure disorders, depression, and atrial fibrillation, and a BIMS score indicating moderate cognitive impairment, was observed self-administering a prescribed nasal spray for allergic rhinitis. The medication aide handed the nasal spray to the resident and instructed them on its use, despite not being certain if the resident had been assessed for safe self-administration. The resident was known to sometimes resist taking the nasal spray but was more compliant when allowed to self-administer. Facility records and interviews with the Administrator and Director of Nursing confirmed that no residents had self-administration rights at the time of the incident. The facility's policy required a mini mental assessment, medical director approval, and demonstration of capability before granting self-administration rights. However, these steps had not been completed for this resident, and staff were expected to administer all medications, including nasal spray, unless self-administration rights were formally granted.