Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medication as required by its policy. The policy states that residents must be assessed at admission using a self-administration tool, and the results should be discussed with the attending physician to obtain an order if appropriate. Medical record review showed that a resident with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory Failure, and Liver Disease had not received a Basic Interview for Mental Status assessment due to being a recent admission. Despite this, the resident was observed independently using a nebulizer treatment in their room without a nurse present, and there was no documented assessment or physician order for self-administration. The DON confirmed that an assessment and physician order should have been in place for self-administration of medications.