Failure to Assess and Supervise Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents did not self-administer medications (SAM) as assessed and according to their care plans. One resident with chronic obstructive pulmonary disease (COPD), mild cognitive impairment, and supraventricular tachycardia required partial to moderate assistance with activities of daily living and was not assessed to self-administer medications. Despite this, an LPN set up a nebulizer treatment for the resident and left the room, not returning for 34 minutes. During this time, the resident was observed repeatedly holding the nebulizer mouthpiece, with no staff supervision or assessment of respiratory status, oxygen saturation, or lung sounds as required by the medication order and care plan. Family members also reported that staff did not stay with the resident during treatments and noted instances where used nebulizer equipment was left unattended for hours. Another resident, admitted with a fracture, hyperthyroidism, and recent orthopedic surgery, was also not assessed for self-administration of medications. The care plan did not indicate the resident could self-administer, and there was no provider order for SAM. However, the resident was observed with a cup of medications left at the bedside by a nurse, and the resident stated the nurse had left them there. The medication administration record confirmed multiple medications were given that morning, but there was no documentation of a SAM assessment. Interviews with staff, including the LPN and DON, confirmed that neither resident had been assessed for self-administration of medications prior to being left alone with their treatments or medications. The facility's policy required a SAM assessment and interdisciplinary team review before allowing residents to self-administer medications, including evaluation of cognitive and physical status, medication appropriateness, storage, monitoring, and documentation. These procedures were not followed for the two residents involved.