Failure to Assess and Monitor Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication and did not track or record the resident's medication use as required. The resident, who was admitted with diagnoses including Acute Respiratory Failure, COPD, and Emphysema, was observed with a nebulizer, CPAP machine, and an Albuterol inhaler at bedside. The resident reported using the inhaler multiple times a day, but staff had not inquired about its use or provided any education regarding the medication. Review of the resident's electronic medical record and medication administration record revealed a lack of documentation regarding assessment, education, or monitoring for the safe and proper use of the inhaler, with only one instance of self-administration recorded despite the resident's reported frequent use. Facility policy requires that residents be assessed by the interdisciplinary care team for the safety and appropriateness of self-administering medications, be educated on side effects, and be regularly observed and monitored, with all actions documented in the care plan and medication administration record. However, there was no evidence that these procedures were followed for this resident. The Director of Nursing confirmed that if the documentation was not present in the record, the required assessments and monitoring likely did not occur.