Failure to Ensure Proper Assessment Before Self-Administration of Medication
Penalty
Summary
A resident with diagnoses including seizure disorders, depression, and atrial fibrillation, and a BIMS score indicating moderate cognitive impairment, was observed self-administering a prescribed nasal spray for allergic rhinitis. The medication aide handed the nasal spray to the resident and allowed them to administer it themselves, despite not being certain if the resident had been assessed for safe self-administration. The aide also stated that the resident was sometimes resistant to taking the nasal spray but might comply when allowed to self-administer. Facility records and interviews with the Administrator and Director of Nursing confirmed that no residents had self-administration rights at the time of the incident. The facility's policy required a mini mental assessment, agreement from the Medical Director, and demonstration of capability before granting self-administration rights. However, this process had not been completed for the resident involved, and staff were expected to administer all medications, including nasal spray, unless self-administration rights were formally granted.