Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
Facility staff failed to assess a resident for self-administration of medications, despite the resident having an Albuterol inhaler in their possession. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and heart failure, was found to be cognitively intact with a BIMS score of 15 out of 15. The resident's care plan included interventions for respiratory conditions, but there was no documentation indicating an assessment for self-administration of medications. The resident was observed keeping the inhaler in their pocket and stated they used it as needed for shortness of breath. Additionally, over-the-counter medications were found in the resident's bedside drawer, which were not on the medication list. A review of the clinical record revealed a provider order for Albuterol as needed, but there was no documentation on the medication administration record for its administration during the month in question. Facility policy required that residents be assessed by the interdisciplinary team for self-administration of medications and that unauthorized medications found at the bedside be given to the charge nurse. Despite these requirements, there was no evidence that the resident had been assessed for self-administration, and the issue was confirmed during a meeting with facility administrators.