Failure to Timely Update Care Plan for Self-Medication Administration
Penalty
Summary
The facility failed to update the care plan for a resident who was authorized to self-administer medication. Despite having an active physician order allowing the resident to keep an inhaler at bedside and self-administer Albuterol as needed, no care plan was initiated at the time the order was received. The care plan was only created several months later, after the deficiency was identified. The facility's own policy requires that a care plan be developed and updated when there is a change in medication scheduling, dose, or the resident's condition, and that the interdisciplinary team must approve and document the resident's ability to self-administer medications. The resident involved had multiple complex diagnoses, including multiple sclerosis, COPD, epilepsy, muscle weakness, diabetes, and asthma. The assessment for self-administration of medications was not completed as required, and the care plan addressing the resident's desire and ability to self-administer medication was not initiated until after the deficiency was noted. This lapse was confirmed by the Regional Nurse Consultant, who acknowledged that the care plan should have been started when the self-administration order was received.