Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
A deficiency occurred when a resident with a history of atrial fibrillation, COPD, and emphysema was allowed to self-administer multiple inhalers without a documented assessment to determine if self-administration was clinically appropriate. The resident was observed to have four inhalers at her bedside, including Arnuity, Spiriva, Albuterol, and Fluticasone, which she obtained from her purse. The resident reported self-administering these medications and keeping the Albuterol inhaler at bedside for emergencies. She also expressed concerns about side effects from one of the inhalers and had refused doses of Arnuity on several occasions. Review of the resident's medical record revealed no documentation of a self-administration of medications assessment, despite the facility's policy requiring an interdisciplinary team evaluation to determine if self-administration was safe and appropriate. Interviews with nursing staff and the DON confirmed that no such assessment had been conducted after admission, even though the resident was provided inhalers at bedside and was self-administering them. The DON stated that the resident was asked about self-administration upon admission and declined, but no further assessments were performed when the situation changed. The facility's policy outlined specific criteria for evaluating a resident's ability to self-administer medications, including physical and cognitive abilities, understanding of medication instructions, and safe storage. However, these procedures were not followed in this case, as the resident was not reassessed for self-administration capability when she began keeping and using inhalers at her bedside. Staff interviews indicated a lack of awareness and oversight regarding the resident's possession and use of multiple inhalers.