Failure to Assess Resident Before Allowing Unsupervised Self-Administration of Inhaler
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer medication, as required by facility policies. The resident was admitted and readmitted with diagnoses including acute respiratory failure with hypoxia and asthma, and was prescribed a Fluticasone Furoate-Vilanterol inhaler for asthma as an unsupervised self-administered medication. Physician orders and MARs for multiple months documented that the resident was self-administering this inhaler daily and unsupervised. However, the IDT care conference record for the resident’s admission showed that the self-medication administration section was left unmarked, and there was no documentation in the conference summary that an IDT assessment for self-administration had been conducted. Further record review showed that the resident’s MDS indicated intact cognition for daily decision-making but dependence or need for assistance with several ADLs, including toileting hygiene, dressing, footwear, personal hygiene, and bathing. Nursing progress notes later documented that the resident reported taking the inhaler on an as-needed basis, despite the physician’s order specifying daily administration. The nurse documented reviewing proper inhaler technique with the resident and seeking clarification from the physician regarding whether the medication should remain a daily routine or be changed to PRN, and the physician confirmed it should be administered once daily as ordered. A care plan for self-administration of medication was initiated and revised later, indicating that the resident self-administers the inhaler and that reassessments would occur periodically, but this was not in place during the earlier period of self-administration. Interviews with staff and family further highlighted the lack of required assessment and oversight. A family member stated that the resident did not receive the inhaler for approximately two and a half months starting from the time of the order. An LVN reported that the resident had been self-administering the inhaler from December through March and stated that there should be a self-medication assessment in the electronic medical record completed by an RN supervisor or charge nurse, but confirmed that she had not completed such an assessment. The MDS nurse stated that residents who self-administer medications should have both a physician’s order and an IDT assessment of their ability to self-medicate, and reported having no knowledge that this resident was self-administering until preparing the quarterly MDS. Review of facility policies confirmed that residents may self-administer medications only if the attending physician and IDT determine, through assessment of mental and physical abilities and specific medication-related skills, that it is clinically appropriate and safe, which had not been documented for this resident during the period in question.
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