Failure to Assess and Authorize Resident Self-Administration of Bedside Medications
Penalty
Summary
Failure to assess and authorize a resident for self-administration of medications occurred when a cognitively intact resident with COPD, coronary heart disease, hypertension, and heart failure had multiple medications stored at bedside without a documented self-administration assessment. The resident’s active physician orders included albuterol sulfate inhaler to be used as needed for dyspnea, but there was no active order for oxymetazoline hydrochloride nasal spray. Review of the medical record showed no documentation that the resident had been evaluated for the ability to safely self-administer medications, despite having these medications in his room. Surveyor observations on multiple days revealed two albuterol inhalers and two oxymetazoline nasal spray bottles in a basket on the overbed table within the resident’s reach while he was in bed. The resident reported using the inhalers about twice a week for shortness of breath and using the nasal spray for congestion. The assigned nurse stated she had administered the resident’s medications but had not noticed the inhalers or nasal sprays at bedside and was unaware of any residents self-administering medications. The DON later confirmed that a self-administration assessment and appropriate physician orders were required if the resident wished to self-administer these medications and that the medications should be stored securely, but at the time of the observations, these steps had not been taken.
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