Failure to Ensure Safe Medication Administration and Oversight
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease and moderate cognitive impairment was found to be self-administering a nasal spray medication without a physician's order or an assessment for self-administration. The resident kept the nasal spray on his side table and used it regularly without informing the nursing staff. There was no documentation in the resident's records of an order for the nasal spray, nor any assessment to determine the resident's competency to self-administer medications. During medication administration rounds, a nurse did not notice the nasal spray in the resident's room and was unaware that the resident was self-administering it. The nurse later acknowledged that medications should not be kept in residents' rooms and that she was unsure if the resident was permitted to self-administer any medication. The Director of Nursing confirmed that medications should be administered by nurses and that a physician's order is required. The facility's policies also require that all medications be administered by licensed personnel and only upon written physician orders. Interviews with staff and the administrator revealed that there was no process in place to ensure that residents were not keeping medications at bedside or self-administering without proper assessment and orders. The administrator stated that residents should not self-administer medications unless assessed as competent, and that staff are expected to check for medications in residents' rooms. The facility's failure to follow these procedures led to the resident self-administering a medication without oversight.