Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for the ability to self-administer medications, as evidenced by two residents who were found to be self-administering medications without proper assessment or physician orders. One resident, who had a diagnosis of chronic obstructive pulmonary disease, was observed using an albuterol inhaler provided by the facility without a documented order to self-administer or store the medication at bedside. The resident's care plan and records did not indicate any assessment or approval for self-administration of medication. Another resident was found with a bottle of bismuth subsalicylate at her bedside, which she reported taking for heartburn and had brought from home. There was no physician order for this medication or for self-administration, and no assessment had been completed to determine her ability to self-administer. Staff interviews confirmed that residents were not allowed to self-administer medications without an assessment and physician order, and that medications found at bedside would be removed. The facility's policy requires an assessment and physician order for self-administration, but this process was not followed for the two residents involved.