Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including COPD, edema, chronic pain, anxiety, hypertension, and atrial fibrillation, was allowed to keep and self-administer a Breztri inhaler at her bedside without a physician's order or a documented assessment of her ability to safely self-administer medications. The resident's medical record indicated moderately impaired cognition and a care plan that directed staff to administer medications as ordered. The self-administration assessment documented that the resident required assistance for all medications, including inhalants, and there was no order permitting self-administration or bedside storage of the inhaler. During medication administration, a licensed nurse discovered the inhaler was not in its box and found it on the resident's bedside table. The resident self-administered the inhaler in the nurse's presence. Facility policy required an interdisciplinary team assessment and a physician's order before allowing self-administration or bedside storage of medications, but these steps were not completed for this resident.