Failure to Assess Resident for Safe Self-Administration of Insulin
Penalty
Summary
The facility failed to ensure that a resident who self-administered insulin was properly assessed for the ability to safely self-administer medication, as required by facility policy. During an observation, a nurse was seen handing an insulin injector to a resident, who then administered the injection without checking the dose. The resident had a physician's order for insulin and had been self-administering for approximately one year, with staff routinely setting up the injector and allowing the resident to inject themselves. However, there was no documented assessment in the medical record to determine if the resident was clinically appropriate or safe to self-administer their medication. Interviews with nursing staff and administration revealed a lack of awareness regarding the need for an assessment or a specific order for self-administration. The DON and ADON were not initially aware of any residents self-administering medications and could not locate an assessment or order for the resident in question. The facility's policy required an evaluation of the resident's mental and physical abilities before permitting self-administration, but this process had not been followed for the resident observed.