Failure to Follow Policy for Self-Administration of Medications
Penalty
Summary
Staff failed to follow acceptable nursing practice by leaving a resident's topical gel and inhaler in the resident's room without proper assessment or authorization for self-administration. The resident, who was alert and oriented but legally blind and diagnosed with diabetes and end stage renal disease, did not have a care plan or physician order permitting self-administration or bedside storage of medications. Facility policy requires an interdisciplinary team assessment and a prescriber's order before a resident can self-administer medications or keep them at bedside, but no such assessment or order was present in the resident's medical record. Observations showed that both the diclofenac sodium topical gel and Breztri inhaler remained on the resident's over bed tables for several hours. Interviews with the resident confirmed self-use of these medications as needed, and interviews with multiple LPNs revealed that the required assessment and physician order for self-administration had not been completed. Staff acknowledged that the resident did not have authorization to self-administer medications, and the medications were subsequently removed from the room after this was discovered.