Failure to Prevent Unsafe Self-Administration of Medication
Penalty
Summary
A resident with chronic obstructive pulmonary disease (COPD) and acute respiratory failure was assessed by the interdisciplinary team and determined to be clinically unsafe to self-administer medications. Despite this assessment, the resident was found to have both a Symbicort inhaler and an albuterol inhaler stored in the drawer of his bedside table. The resident reported that some nursing staff were aware of the Symbicort inhaler being kept in his room, but none of the staff were aware of the albuterol inhaler. The resident also stated he had used both inhalers while in the facility, although he could not recall the specific dates of use. Review of the resident's physician orders confirmed that only the Symbicort inhaler was prescribed, with no order for albuterol or for any medications to be kept in the resident's room for self-administration. Nursing staff interviewed were unaware of the presence of the inhalers and stated that medications should not be kept in a resident's room unless the resident was assessed as safe to self-medicate and had a physician's order. Facility leadership confirmed that medications should be removed if found in the room of a resident not approved for self-administration.