Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a proper assessment was conducted to determine the clinical appropriateness of self-administration of medications for a resident with multiple chronic conditions, including chronic respiratory failure, COPD, and moderate cognitive impairment. The resident was observed with an albuterol inhaler at his bedside and reported that staff allowed him to keep and use the inhaler as needed. However, there was no documentation in the electronic medical record of a self-administration assessment or a physician's order permitting the resident to self-administer the inhaler or to keep it at the bedside. The resident's care plan did not reflect the ability to self-administer medication, and the physician's order only specified the medication and dosage, not self-administration privileges. Interviews with staff, including an LPN, RN, and the DON, confirmed that an assessment should have been completed and documented before allowing the resident to self-administer medication. Staff were unable to locate any such assessment in the resident's record, and the DON acknowledged uncertainty about whether the assessment had been completed. The lack of assessment, physician's order, and care plan documentation led to the deficiency in ensuring safe and clinically appropriate self-administration of medication for the resident.