Failure to Assess Resident for Self-Administration of Inhalers
Penalty
Summary
The facility failed to complete a comprehensive assessment for self-administration of medications for a resident with chronic obstructive pulmonary disease (COPD) and asthma, who was oxygen dependent and had moderately impaired cognition. The resident's care plan included interventions for respiratory impairment, and physician orders specified the use of Ventolin and Dulera inhalers. Despite these orders, the resident was found to be self-administering both inhalers, keeping them in her pocket, and had not received a comprehensive assessment to determine her ability to safely self-administer these medications. There was also no physician order authorizing self-administration, as required by facility policy. Multiple staff members, including RNs, were aware that the resident had been self-administering her inhalers for at least two weeks, but no assessment had been completed. The resident reported keeping the inhalers on her person for quick access and had informed staff of her desire to self-administer, but was told the inhalers should be kept in the medication cart. The DON confirmed that no self-administration assessment had been completed, and the facility's policy required both a prescriber's order and an interdisciplinary team determination of safety before allowing self-administration of medications.