Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to perform a resident assessment for self-administration of prescription medication for a resident diagnosed with dementia and chronic obstructive pulmonary disease. The resident, who was admitted to the facility with a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, was observed with two medication cups containing a white cream in his room. The resident reported that staff left the cream for him to apply to a rash on his chest, although he did not know the name of the cream. A Registered Nurse (RN) confirmed that the resident had an order for staff to apply hydrocortisone cream to the rash, but the resident insisted on applying it himself. The RN admitted to leaving the cream in the resident's room without the interdisciplinary team discussing or determining the resident's safety in self-administering the medication. The Director of Nursing (DON) confirmed that there was no documentation in the electronic medical record (EMR) of an assessment to determine the resident's capability to self-administer the cream, which was against the facility's policy that requires an interdisciplinary team assessment before allowing self-administration of medication.