Failure to Complete Self-Administration Assessment and Obtain Orders for Bedside Medications
Penalty
Summary
Surveyors observed that a resident had an unopened box of Salonpas medicated pain relief patches and a Breo Ellipta inhaler stored on the overbed table in the resident’s room on multiple occasions. The resident, who had diagnoses including COPD and was admitted earlier in the month, was seen in the room with these medications present, and the inhaler remained at bedside even when the resident was not in the room. The resident’s care plan indicated there was a physician’s order for self-administration of inhalers, and a self-administration of medication assessment documented that the resident wished to self-administer some medications that would be stored in the room, but the specific medications were not identified. Record review showed a physician’s order for fluticasone-salmeterol 100/25 mcg inhaler to be administered as one puff twice daily, but there was no physician’s order authorizing the resident to self-administer this inhaler. There was also no physician’s order for the Salonpas patches, which the resident had brought into the facility. The self-administration assessment did not specify which medications the resident was permitted to self-administer, and the medications were not stored in a lockbox or locked drawer as referenced in facility policy. During interview, facility leadership acknowledged that the care plan referenced self-administration of the inhaler, but this was not reflected in the physician’s orders or the medication assessment, and that the Salonpas patches had been found without orders and removed from the room.
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