Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were clinically assessed and authorized to self-administer medications before allowing them access to their medications at bedside. In one instance, a resident with chronic respiratory failure, COPD, and a BIMS score indicating cognitive intactness was observed with a Combivent Respimat inhaler and a mouth spray on the bedside table. The resident stated the items had been there for at least a day but could not recall who placed them there. Review of the resident's records showed a self-administration assessment and plan of care only for nebulizer use after nurse setup, with no assessment or plan for the inhaler or mouth spray. Interviews with nursing staff confirmed that the resident was not authorized to self-administer these medications and that such medications should not be left at bedside without proper assessment and physician order. Another resident, also with chronic respiratory failure, COPD, and a BIMS score indicating cognitive intactness, was observed with a cup of medications left on the meal tray at bedside. The resident reported receiving the medication cup that morning. When questioned, the medical assistant confirmed that the resident liked to take medications independently but could not find documentation of an assessment or physician order authorizing self-administration. The nurse supervisor later clarified that the resident was only authorized to self-administer topical creams, not oral medications, and that oral medications should not be left on the meal tray. The facility's policy requires that residents wishing to self-administer medications must undergo a self-administration assessment, and if deemed safe, a physician order must be obtained. Additionally, medications must be kept in a secure location between administrations. In both cases, the facility did not follow its own policy, as neither resident had the required assessment or physician order for the medications found at bedside, and medications were not secured as required.