Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to assess whether a resident's right to self-administer medication was clinically appropriate, as required by facility policy. Specifically, the policy states that the interdisciplinary team (IDT) must evaluate each resident's cognitive and physical abilities to determine if self-administration of medications is safe and appropriate. In the case reviewed, a resident with diagnoses including lung cancer, hypertension, and COPD had a physician's order for a Combivent Respimat inhaler to be kept at bedside for self-administration as needed. Despite the presence of the inhaler at the resident's bedside and the standing order allowing self-administration, there was no documented assessment in the clinical record of the resident's cognitive or physical ability to self-administer the medication. Staff confirmed that no such assessment had been completed to determine if self-administration was clinically appropriate for this resident.