Failure to Prevent Unauthorized Self-Administration of Medication
Penalty
Summary
Facility staff failed to ensure that a resident was properly assessed and approved for self-administration of medications. The resident, who had diagnoses of hypertension, generalized weakness, and diabetes mellitus, was admitted to the facility and had a self-administration assessment indicating a need for assistance with ointments and topical medications. The assessment specifically stated that the resident was not approved for self-administration or for keeping medications at the bedside. Despite this, during an observation, the resident was found with two creams and a powder medication at the bedside, which the resident identified as prednisolone cream, Vitamin A&D ointment, and athlete's foot powder. A Licensed Vocational Nurse confirmed that these medications should not have been left at the bedside, as the resident was not approved for self-administration and all medications should be administered by licensed staff and securely stored. The Director of Nursing stated that the facility's process requires an assessment and a physician's order for self-administration, and that medications should not be left with residents who are not approved, to prevent potential medication errors. The facility's policy also requires IDT and physician determination before allowing self-administration, which was not followed in this case.