Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including type 2 diabetes, chronic kidney disease, hypertension, major depressive disorder, and long-term insulin use was not assessed for self-administration of medications. The resident had an intact cognitive status, as indicated by a BIMS score of 15, and had physician orders for Creon and Tramadol. Despite this, the resident was found to have pill bottles of both medications in their room and self-administered Creon without a physician's order or documented assessment for self-administration. The resident reported keeping medications in their drawer due to previous instances where the facility failed to provide medications as ordered, resulting in pain, vomiting, and diarrhea. Staff interviews confirmed that the resident did not have an order or assessment for self-administration, and that Tramadol, a controlled substance, should not have been at the bedside. The facility's policy requires a written physician order and assessment before a resident can self-administer or retain medications in their room. Review of the resident's records showed no such order or care plan in place for medication self-administration.