Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A resident with diagnoses of congestive heart failure, chronic obstructive pulmonary disease, and depression was found to have an expired bottle of over-the-counter Vicks VapoRub on the bedside tray table. The resident reported self-administering this medication regularly for nasal use and stated that the nursing staff was aware of this practice. Review of the resident's records showed no documentation of an interdisciplinary team (IDT) assessment to determine the safety and appropriateness of self-administration, nor was there a physician order authorizing the resident to self-administer this medication. During interviews, a licensed vocational nurse confirmed the expired medication was present and that there was no physician order for self-administration. The director of nursing was unaware of the resident's self-administration and acknowledged that an IDT assessment and physician order should have been in place. Facility policy requires an IDT assessment and a physician order specifying which medications a resident may self-administer, but these steps were not completed for this resident.