Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
The facility failed to assess and ensure that a resident had an order to self-administer a prescribed medication. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and hyperglycemia, was found to have two tubes of prescription triamcinolone acetonide ointment at her bedside. The resident reported that certified nursing assistants (CNAs) would apply the ointment to her buttocks daily or upon her request, and that the medication was prescribed by her outside physician. The Minimum Data Set indicated the resident had intact cognition and required some assistance with personal care tasks. During interviews, a CNA stated she applied the ointment to multiple areas as directed by the resident, believing it was approved, but did not confirm with a charge nurse. The CNA acknowledged that only licensed nurses should administer medications. An LVN explained that a formal assessment and physician order are required before a resident can self-administer medications, and that leaving medication at the bedside could result in improper use. The Director of Nursing confirmed that medication should not be left at the bedside without an order, as this could be dangerous. Facility policy indicated only licensed personnel may administer medications.