Failure to Complete Assessment and Obtain Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a self-administration of medication (SAM) assessment was completed and a provider order was obtained for a resident to self-administer medications. The resident in question had severely impaired cognition, Alzheimer's disease, heart failure, and anxiety, and required significant assistance with personal and oral hygiene. Documentation showed that the resident did not wish to self-administer medications, and there was an active order stating the resident was not capable of safely self-administering medications. Despite this, staff left the resident unsupervised to complete a nebulizer treatment in her room, without a provider order or documented assessment supporting her ability to self-administer the treatment. Observation revealed that a trained medication aide set up the nebulizer treatment and left the resident alone in her room while the treatment was ongoing. The aide later confirmed that there was no provider order or assessment in place allowing the resident to self-administer the nebulizer treatment. Interviews with nursing staff and review of the resident's records confirmed that staff were expected to remain with the resident during such treatments and that the facility's policy required both an assessment and a provider order for self-administration. The facility's policy was not followed, resulting in the resident being left unsupervised during medication administration without the necessary documentation or authorization.