Failure to Assess and Monitor Resident Self-Administration of Medications
Penalty
Summary
The facility failed to follow its own policy and procedure for self-administration of medications for one resident. The resident, who had a history of a right leg wound, left leg fracture, and hypertension, was not assessed for the ability to self-administer medications prior to being allowed to do so. Despite having intact cognition and independence in self-care activities, there was no documented assessment by the interdisciplinary team or nursing staff to determine the resident's competency in self-administering medications, as required by facility policy. During observations, the resident was found storing and self-administering over-the-counter nasal spray and eye drops at the bedside without staff knowledge or oversight. The medications were not kept in a locked container, and the resident reported purchasing and using these medications independently for over a month. Nursing staff were unaware of the resident's self-administration practices, and there were no physician orders or documentation in the medical record for these specific medications. Additionally, there was no log or monitoring of the resident's self-administration, contrary to facility policy. Interviews with nursing staff and the DON confirmed that the facility's policies require an assessment, physician order, and proper storage of self-administered medications. The policies also mandate that self-administration be tracked and that medications stored at the bedside be secured to prevent access by other residents. These procedures were not followed, as evidenced by the lack of assessment, absence of orders, unsecured medication storage, and no monitoring or documentation of the resident's self-administration activities.