Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for their ability to self-administer medication, as required by facility policy. The policy stated that if a resident wished to self-administer medication, the interdisciplinary team must complete a specific assessment to determine the resident's capability. In this case, a resident with a history of COPD and pneumonia, who had intact cognition as evidenced by a BIMS score of 15, was observed with an inhaler at their bedside. The resident reported using the inhaler as needed and confirmed that staff were aware of this practice. Record review showed there was no physician order permitting the resident to self-administer the inhaler, nor was there documentation of an assessment for self-administration. Interviews with staff, including a CNA, LVN, and RN, confirmed that the resident kept the inhaler at their bedside and self-administered it without the required assessment or physician order. The facility's DON also confirmed that the necessary procedures for self-administration had not been followed in this case.