Failure to Assess and Supervise Self-Administration of Nebulizer Medication
Penalty
Summary
A resident with severe cognitive impairment and diagnoses including Alzheimer's disease, diabetes mellitus, and hypertension was observed self-administering a nebulizer treatment without having been assessed for the ability to safely self-administer medications. The resident required extensive assistance with bed mobility, transfers, toileting, and personal hygiene, and there was no completed self-administration of medications (SAM) assessment or physician order permitting self-administration in the resident's electronic health record. The care plan directed staff to administer all medications as ordered by the physician. During observation, an LPN prepared and placed the nebulizer mask on the resident and then left the room, leaving the resident unattended. The resident subsequently removed the mask with medication still being dispensed and left the room, leaving the nebulizer mask on the bed. Interviews with the LPN, RN, and DON confirmed that no SAM assessment had been completed and that staff were expected to remain with the resident during nebulizer administration in the absence of such an assessment or physician order. Facility policy required nurses to assess each resident's mental and physical abilities before permitting self-administration of medications.