Unauthorized Resident Possession of Rescue Inhaler and Improper Medication Storage
Penalty
Summary
The facility failed to ensure medications were stored properly and that drugs were maintained in locked compartments as required, as evidenced by one resident keeping a rescue inhaler on his/her person without an order for self-administration. During an interview, the Nursing Home Administrator (NHA) stated that the resident was a hoarder and always had a safety inhaler in his/her pocket, and acknowledged seeing a blue inhaler in the resident’s hand but did not verify whether it contained medication. The NHA also stated that residents should only have medications at the bedside if there was an order, and she was unsure whether this resident had such an order. In a separate interview, the resident confirmed having an albuterol rescue inhaler with medication in it in his/her pocket and stated an intention to keep the medication on his/her person to use when he/she felt it was needed, rather than relying on nursing staff. Review of the medical record showed the resident had diagnoses including COPD with acute exacerbation, heart failure, and other abnormal lung findings, and that on an admission/readmission nursing evaluation the resident was documented as not wanting to self-administer medications. The record contained an order for albuterol sulfate HFA inhaler to be administered as 1 puff every 4 hours as needed for wheezing related to COPD, but there was no order for self-administration of any medications. The albuterol order specified that it was to be administered by a clinician, not by supervised or unsupervised self-administration, confirming that the resident’s possession and control of the inhaler was not authorized by provider orders or facility policy.
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