Failure to Assess and Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for safe self-administration of medication, specifically regarding the use of an inhaler at bedside. During observation, the resident was found with an inhaler on the bedside table that lacked a name or open date, and the resident stated she was allowed to keep it at bedside. Staff interviews revealed inconsistency in the application of facility policy, with a LPN stating that residents are generally not supposed to have medications at bedside unless there is an order, and confirming that she would need to check for such an order. Further review showed that the required self-administration assessment for the resident was not completed on the date it was due, but was instead finalized several months later. The care plan for the resident, who has multiple chronic conditions including multiple sclerosis, COPD, epilepsy, muscle weakness, diabetes, and asthma, was only initiated after the assessment was completed late. Facility policy requires that residents who self-administer medications must be assessed for their ability to do so safely, and that medications kept at bedside must be stored in pharmacy-provided packaging with proper labeling. Staff interviews confirmed that the inhaler was not stored according to these requirements, lacking both the original packaging and necessary labeling. The physician order for the resident did allow for the inhaler to be kept at bedside, but the interdisciplinary team assessment and proper documentation were not completed in a timely manner, resulting in a failure to ensure safe medication self-administration and storage.