Failure to Assess and Care Plan Resident for Self-Administration of Bedside Inhaler
Penalty
Summary
The facility failed to ensure a resident’s right to self-administer medications was protected in accordance with its own bedside medication storage policy. The policy required a prescriber’s written order, an interdisciplinary team assessment of self-administration skills, documentation of bedside storage on the MAR and care plan, resident instruction with documentation, and at least once-per-shift nursing checks for usage. For a cognitively intact resident with COPD who had an order for albuterol inhaler "may keep at bedside," the care plan did not address self-administration, and there was no documented assessment of the resident’s ability to safely self-administer medications. The resident reported wanting to keep the rescue inhaler at bedside and stated that the physician had ordered this, but staff initially did not provide the inhaler, telling the resident they needed to speak with the physician. On subsequent observation, the resident produced the albuterol inhaler from the bedside drawer and stated staff had given it to be kept at bedside. Review of the medical record at that time still showed no assessment for self-administration. A CMT reported that if a resident is able to self-administer, the order would indicate the medication may be left at bedside and that residents are educated on proper technique, but also stated there were currently no residents self-administering medications. The DON stated the resident had been assessed in the past but was unsure if reassessment occurred after the last admission, and confirmed that residents requesting to self-administer should be assessed for safety when medications are kept at bedside.
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