Failure to Ensure Safe Self-Administration and Accurate Medication Documentation
Penalty
Summary
The facility failed to ensure services met professional standards of quality for a resident with COPD and moderate cognitive impairment. The resident, admitted in November 2025 and scoring 12 on the BIMS, was observed on the morning of 2/5/26 self-administering a nebulizer treatment alone in her room without staff present. The resident reported she had always given herself the nebulizer treatment. During an interview and observation, LN B confirmed the resident had administered the nebulizer treatment herself, acknowledged there was no physician order for self-administration, and that no self-medication administration assessment had been completed. LN B also verified that more than 1 ml of medication remained in the nebulizer cup when the treatment was stopped. The DON later confirmed there was no order or assessment authorizing the resident to self-administer medications, despite facility policy requiring both before self-administration. The facility also failed to ensure accurate medication documentation for the same resident. Review of the EMAR for 2/5/26 showed that polyethylene glycol had been documented as administered at 9:00 a.m. The resident stated she had not received her laxative, which she expected to be mixed with water in a disposable cup. When challenged by the resident to locate the used cup in the trash, LN B checked the trash can, found no cup, and then recalled she had not actually given the laxative. During a concurrent record review, LN B verified that the EMAR indicated the polyethylene glycol had been administered and acknowledged she had not followed facility policy, which required documenting medication administration on the EMAR only after the medication was actually given. The DON confirmed the facility policy required immediate documentation after administration and stated that documenting a medication as given when it was not could mislead clinical decisions and put resident safety at risk.
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