Failure to Develop and Implement Care Plan for Self-Administration of Medication
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had received a physician's order to self-administer inhaler medications. Despite documentation indicating the resident was capable of self-administering medications, including storing them securely, managing containers, and understanding medication schedules and refusals, there was no corresponding care plan addressing this aspect of care. The resident's medical record included a diagnosis of hypertension and COPD, with assessments showing moderately impaired thought processes and a need for maximal assistance with activities of daily living. Record reviews and interviews confirmed that the care plan did not reflect the physician's order or the resident's ability to self-administer medication, as required by facility policy. The Director of Nursing acknowledged that the care plan should have been updated to address the resident's physical and psychological needs related to self-administration of medication. Facility policies reviewed also specified that such care plans must be developed and implemented when self-administration is deemed safe and appropriate.