Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and muscle weakness was found to have two inhalers at their bedside without documentation of an assessment for safe self-administration of medication. The resident stated that staff were aware of the inhalers in the room and explained that they used the inhaler during COPD flare-ups, expressing concern about delays if they had to wait for staff assistance. Observation confirmed the presence of both inhalers, and staff interviews revealed uncertainty regarding whether the resident was authorized or assessed to self-administer these medications. A CNA reported the presence of the inhalers to the charge nurse but was unaware of any authorization for self-administration. An LPN confirmed knowledge of the requirement for assessment prior to residents keeping medications at the bedside but did not know if this had occurred for the resident in question. The LPN checked the inhalers and left them in the room, stating he would follow up with administration. The Corporate Director of Nursing Services later acknowledged that the resident did not have an order or assessment for self-administration of inhalers.