Failure to Secure Medications and Assess for Safe Self-Administration
Penalty
Summary
A deficiency occurred when a resident was allowed to keep an inhaler at the bedside without an assessment for safe self-administration and without a physician's order authorizing the medication to be kept at the bedside. Multiple observations over several days confirmed the inhaler was in plain view on the resident's bedside table, and the empty inhaler box was also present in the room. The resident reported using the inhaler as needed and stated that staff had previously left it in her room because she did not always require it when offered. The resident did not notify staff when using the inhaler. Facility policy required an interdisciplinary team assessment and a physician's order for self-administration of medications at the bedside, neither of which had been completed for this resident. The LPN was unaware that the resident had the inhaler at the bedside and confirmed there was no request for it. The DON acknowledged that no assessment or order was in place for the resident to self-administer the inhaler. The resident was cognitively intact, with a BIMS score of 15, and had diagnoses of chronic bronchitis and asthma, with a standing order for the inhaler as needed for shortness of breath.