Failure to Assess and Document Resident's Self-Administration of Medication
Penalty
Summary
The Interdisciplinary Team (IDT) failed to ensure that a resident was properly assessed for the ability to self-administer an Albuterol inhaler, as required by facility policy. The resident, who had multiple diagnoses including Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Schizophrenia, and Anxiety, was observed to have moderately impaired cognitive status and required supervision with activities of daily living. Despite these factors, the resident was allowed to keep an Albuterol inhaler in her purse and self-administer it without documented assessment by the IDT to determine if this was clinically appropriate and safe. Additionally, there was no documentation in the Medication Administration Record (MAR) indicating when the resident used her inhaler over a two-week period, and staff were unable to clarify who was responsible for documenting its administration. The facility's policy required an assessment of the resident's mental and physical abilities and clear documentation responsibilities, neither of which were followed in this case. The Director of Nursing confirmed that the required assessment had not been completed.