Failure to Assess and Authorize Self-Administration of Nebulizer Medications
Penalty
Summary
The provider failed to ensure that two residents were properly assessed for their ability to safely self-administer nebulizer medications, as required by facility policy. In the case of one resident with moderate cognitive impairment (BIMS score of 12), staff set up the nebulizer medication and left the resident to self-administer the treatment without remaining in the room or directly supervising the process. There was no physician's order authorizing self-administration, no assessment documenting the resident's capability to self-administer, and the care plan did not reflect self-administration of medications. Staff confirmed that these required steps had not been completed. Similarly, another resident, who was cognitively intact (BIMS score of 15), was observed independently inhaling a nebulizer treatment without staff present. Although the resident had received initial education and supervision, staff subsequently left him alone to complete the treatments. There were no physician's orders, assessments, or care plan documentation supporting his ability to self-administer the nebulizer medication. The facility's policy requires a self-medication evaluation, a physician's order, and care plan updates before allowing residents to self-administer medications, none of which were completed for these residents.