Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a self-administration of medications assessment was completed for a resident who was observed with medication at their bedside. The resident, who had intact cognition and diagnoses including morbid obesity and asthma, was found to have an albuterol inhaler at their bedside, which they used as needed without notifying staff. The resident's most recent self-administration assessment indicated they did not wish to self-administer medications, and their care plan did not address self-administration. However, the resident kept and used the inhaler independently several times a week. Staff interviews confirmed that when a medication is found in a resident's room, it should be removed and an assessment should be completed to determine if self-administration is safe, followed by obtaining a provider order if appropriate. In this case, although there was a provider order for the inhaler, there was no order or documented assessment for self-administration, nor was it addressed in the care plan. The facility's policy requires an interdisciplinary assessment and documentation in the medical record and care plan if self-administration is deemed safe and appropriate, which was not followed in this instance.