Failure to Ensure Physician's Order and Assessment for Self-Administration of Medication
Penalty
Summary
A resident with diagnoses including congestive heart failure and chronic obstructive pulmonary disease was observed to have fluticasone propionate nasal spray on their bedside table. The resident reported self-administering the nasal spray once daily, despite a physician's order indicating it should be administered twice daily. Review of facility policy indicated that residents who self-administer medications must have a physician's order and a self-administration assessment, with monthly counseling and documentation. Interviews with facility staff, including an LPN and the DON, confirmed that there was no documented order or assessment for the resident to self-administer the nasal spray. The LPN stated that initial education was provided to the resident regarding the medication, but no ongoing education or assessment was documented. The absence of a physician's order and a self-administration assessment for the medication constituted a failure to follow facility policy and regulatory requirements for medication administration.