Failure to Assess and Care Plan for Self-Administration of Nebulized Medications
Penalty
Summary
The facility failed to comprehensively assess and care plan a resident's ability to self-administer nebulized medications. The resident, who had intact cognition and diagnoses including a circulatory disorder, aneurysm, and COPD, was observed receiving prepared nebulizer medication from an LPN, who then left the resident to self-administer the medication independently. The care plan for the resident included interventions for altered respiratory status and directed staff to administer medications as ordered, but did not include any evidence of an assessment or approval for the resident to self-administer nebulized medications. Interviews with staff revealed that the LPN assumed an assessment had been completed and routinely left multiple nebulized medications with the resident to self-administer during the night, checking back later to confirm administration. The RN responsible for assessments confirmed that no formal assessment or order for self-administration had been completed, as she was unaware the resident was independently administering the medications. The DON stated that facility policy required a self-administration assessment and care planning if a resident requested to self-administer medications, but this process had not been followed for the resident in question.