Failure to Conduct Medication Self-Administration Assessment
Penalty
Summary
The facility failed to conduct a medication self-administration assessment for a resident who was observed with a box of Ocusoft Retaine MGD ophthalmic emulsion at his bedside. The resident, who was admitted with diagnoses including a left tibia fracture, muscle weakness, and polyneuropathy, had a Brief Interview for Mental Status score of 15 out of 15, indicating cognitive intactness. Despite this, there was no physician's order for the eye drops, which the resident stated he used for his eyes. The primary RN acknowledged the presence of the eye drops and confirmed that there were no physician orders for them. The Director of Nursing stated that residents should have a completed self-administration assessment and a physician's order before self-administering medications. The facility's policy requires that residents who wish to self-administer medications must be assessed and determined capable of doing so, which was not done in this case.