Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were not kept at a resident's bedside without a physician's order and did not assess the resident for safe self-administration of medication. During medication administration, an LPN was observed with a resident who had several medications, including triamcinolone lotion, two nasal spray bottles, and caladryl lotion, on her bedside tray table. These medications were not labeled, and the resident reported self-administering them daily and as needed for rashes and itchiness. The resident was alert and oriented, able to verbalize her needs, and stated that the nursing staff were aware of her self-administration practices. Upon review, it was found that there were no physician orders for the nasal spray and caladryl lotion, nor was there an order allowing the resident to keep medications at her bedside. Additionally, no assessment had been completed by the interdisciplinary team to determine the resident's capability for self-administration, and there was no care plan in place for this. Facility policy requires a written physician order and an assessment for self-administration, as well as proper storage of bedside medications, none of which were followed in this case. The resident's medical history included acute and chronic respiratory failure, congestive heart failure, paraplegia, congenital deformity of the spine, spina bifida, and allergic rhinitis.