Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was properly assessed and authorized to self-administer nebulizer medications. The resident, who was cognitively intact but dependent on staff for transfers and toileting due to a hip fracture and right ankle fracture, was observed on multiple occasions independently using a nebulizer in her room without staff present. Documentation review revealed that the resident's care plan and electronic health record did not include any assessment or authorization for self-administration of medications, nor was there a physician's order permitting this practice. The resident's medication orders directed staff to administer the nebulizer treatments, but there was no documentation supporting self-administration. Interviews with facility staff, including an LPN, resident care manager, and DON, confirmed that the required self-administration assessment had not been completed, and the process outlined in the facility's self-medication policy was not followed. The policy required a provider's order, a completed assessment to determine appropriateness, and care plan documentation for self-administration, none of which were present for this resident. Staff acknowledged that the resident was self-administering her nebulizer after staff set it up, despite the lack of required assessments and documentation.