Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to complete a comprehensive assessment for self-administration of medication for one resident with chronic respiratory failure and hypoxia. The resident had physician orders for albuterol inhaler use as needed for shortness of breath, with specific instructions for administration. Observation revealed that the resident kept an albuterol inhaler, nystatin powder, and a nebulizer machine at the bedside and self-administered the inhaler without staff supervision. The resident stated that staff had given clearance to use the inhaler independently. However, the care plan did not document self-administration of medications or permission for medications to be kept at the bedside, and no assessment for self-administration was found in the medical record. Interviews with nursing staff and the DON confirmed that there was no order or completed assessment for the resident to self-administer medications or to keep them at the bedside. Staff acknowledged that medications should not be kept at the bedside without proper assessment and physician order. The facility's policy requires an interdisciplinary team assessment to determine if self-administration is safe and appropriate, with documentation in the medical record and care plan, and secure storage of self-administered medications. These steps were not followed in this case.