Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, asthma, and gastroesophageal reflux disease (GERD) was observed on multiple occasions with Tums (calcium carbonate) and an inhaler at the bedside. The resident reported self-administering Tums as needed for heartburn, and the inhaler was also kept at the bedside. Review of the resident's medical record showed that while there were physician's orders for the use of albuterol sulfate and calcium carbonate as needed, there were no specific orders permitting self-administration of these medications. Additionally, there was no documented assessment to determine the resident's ability to safely self-administer medications, nor was there a care plan addressing self-administration. The facility's policy required both a clinical assessment and a specific skill assessment to determine appropriateness for self-administration, but these steps were not completed for this resident. The DON was unable to provide further information regarding the lack of documentation.