Failure to Obtain Physician Orders and Assessments for Self-Administration of Medication
Penalty
Summary
The facility failed to obtain physician orders and conduct appropriate assessments for residents to self-administer medications at their bedside. Specifically, two residents, both assessed as cognitively intact according to their Minimum Data Set (MDS) and Brief Interview Scores, were observed with Ventolin HFA inhalers at their bedside tables. Both residents reported having the inhalers at their bedside for over a month and confirmed recent use. However, a review of their clinical records revealed no documentation of a physician order permitting self-administration or to keep the medication at bedside, nor was there evidence of a completed assessment to determine their ability to safely self-administer the medication. Staff interviews confirmed that facility policy requires a physician order and an interdisciplinary team assessment before allowing residents to self-administer medications or keep them at bedside. Both an LPN and the Director of Nursing stated that these steps are necessary to prevent misuse, overuse, or access by other residents. Despite this, the required documentation and orders were not present in the records for either resident, and the medications remained accessible at their bedside.