Failure to Complete Self-Administration Assessment for Bedside Medication
Penalty
Summary
The facility failed to ensure that a self-administration of medications (SAM) assessment was completed and appropriate orders were obtained for all medications kept at bedside for a resident. Specifically, a resident with diagnoses including diabetes, heart failure, and COPD was observed with an Advair inhaler at their bedside, which had not been documented as safe for self-administration in the resident's SAM assessment. The assessment only indicated that Bio Freeze and nicotine gum were approved for bedside self-administration, not the Advair inhaler. During medication administration, staff were unable to locate the resident's Advair inhaler in the medication cart and subsequently found it on the resident's bedside table, accessible to the resident. The director of nursing confirmed that the SAM assessment did not authorize the resident to keep Advair at bedside and stated that only medications identified as safe in the SAM assessment should be left at bedside. The facility's policy required that resident choices regarding medication administration be evaluated for safety, but this process was not followed for the Advair inhaler.