Failure to Assess Resident for Safe Self-Administration of Nebulizer Medications
Penalty
Summary
A deficiency occurred when a resident was observed self-administering nebulizer medications without a documented assessment of their ability to do so safely, as required by facility policy. During a medication pass, an LPN prepared and set up the resident's nebulizer treatment, placed the mask on the resident, and then left the room, stating she would return after the treatment was complete. The LPN confirmed that by leaving the resident alone, the resident was self-administering the medication, and she could not verify that the full dose was taken. The LPN also stated she was unaware of any completed assessment for the resident's ability to self-administer medications. Review of the resident's medical record showed no physician's order for self-administration, no completed self-administration assessment, and no mention of self-administration in the care plan. Interviews with the resident, the DON, and the administrator confirmed that no residents in the facility had been assessed for safe self-administration of medications, and the expectation was that staff should remain with residents during nebulizer treatments unless an assessment had been completed. Facility policy requires an interdisciplinary team assessment and care plan documentation before allowing self-administration of medications, which was not followed in this case.