Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to complete a self-administration of medications (SAM) assessment for a resident who was observed with medications at bedside. The resident had intact cognition and multiple diagnoses, including cancer, malnutrition, asthma, chronic obstructive pulmonary disease, and required oxygen therapy. The resident was prescribed antipsychotic, antianxiety, antidepressant, and narcotic pain medications, as well as nebulizer treatments and supplemental oxygen. Despite these needs, there was no documentation of a SAM order or assessment in the resident's medical record, medication administration record, or care plan. During observation, a nebulizer machine with a cup two-thirds full of solution and an empty medication vial were found in the resident's room, accessible to the resident. Nursing staff confirmed that the resident did not have a SAM order or assessment and that the nebulizer should not have been left for self-administration. Facility policy requires an interdisciplinary team assessment and care plan documentation before allowing self-administration of medications, which was not completed in this case.