Failure to Supervise Nebulizer Medication Administration
Penalty
Summary
A resident with diagnoses including arthritis, hypertension, and COPD, who required extensive assistance with activities of daily living, was observed self-administering nebulizer treatments without having been assessed as safe to do so. The resident's care plan indicated dependence on staff for medication administration, and a self-administration of medication (SAM) assessment documented that the resident did not wish to self-administer medications. Physician orders directed staff to administer nebulizer medications, and there was no order permitting self-administration. During observation, a trained medication aide prepared and placed the nebulizer mask on the resident, then left the room and was not within visual sight of the resident during the treatment. The aide returned after the treatment period, found the mask removed by the resident, and repeated the process for a second medication. Interviews with staff confirmed that the resident had not been assessed as safe to self-administer medications and that facility policy required staff to remain present unless a SAM assessment and physician order permitted self-administration. The facility failed to ensure safe administration of nebulizer medications by not supervising the resident as required.