F0554

D

Failure to Assess Resident for Self-Administration of Nasal Spray Kept at Bedside

Wichita, Kansas Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident was assessed for the ability to safely self-administer a prescribed Fluticasone propionate nasal spray before allowing the medication to be kept at bedside. The resident’s EMR documented diagnoses of allergic rhinitis, anxiety disorder, and unspecified dementia, with annual and quarterly MDS assessments showing a BIMS score of 13, indicating intact cognition, and no impairment in upper or lower extremities. The Psychotropic Drug Use CAA indicated his medications were managed and overseen by the nurse and physician team, and his care plan did not document that he kept the nasal spray at his bedside. The physician’s order specified daily use of Fluticasone propionate nasal suspension for allergic rhinitis, but the Assessment tab lacked the facility’s Self-Administration of Medication/Treatment Data Collection Tool for this medication.

During observation, the resident was seen seated in a recliner with a bottle of Fluticasone propionate nasal spray on the dresser directly in front of him, and he stated he administered the nasal spray himself when he felt “stopped up,” rather than on a set schedule. A subsequent observation again found the nasal spray on his dresser. Facility staff, including a licensed nurse and an administrative nurse, confirmed that if a resident had medication in the room, an assessment for self-administration should have been completed, and that no such assessment existed for this resident’s nasal spray. The facility’s self-administration policy stated that resident competency must be assessed by the interdisciplinary team prior to allowing self-administration and that such assessments should be performed annually and after significant changes of condition, but this process was not followed for the resident’s nasal spray.