Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed and had physician's orders to self-administer medications for four residents reviewed. Multiple observations revealed that medications, including throat lozenges, eye drops, nebulizer treatments, topical pain medication, and nasal sprays, were found in residents' rooms and accessible for self-administration without appropriate documentation or current physician orders. In several cases, medications were left at the bedside or in personal storage, and residents reported using them independently as needed. For one resident with COPD and chronic respiratory failure, a bag of throat lozenges was observed in the room without a physician's order, and the last self-administration assessment was over a year old. Another resident with neurocognitive disorder and cerebral aneurysm had eye drops at the bedside, but there was no order or assessment for self-administration, and the resident was cognitively impaired. A third resident, who was cognitively intact but required partial assistance with ADLs, had a nebulizer, Biofreeze, and Fluticasone in his room, with no orders for self-administration or for the medications to be kept at the bedside, and the assessment did not document capability for topical medication administration. A fourth resident, also cognitively intact but requiring substantial assistance with ADLs, had a nasal spray and topical steroid on the bedside table, with the most recent self-administration assessment being nearly a year old. The facility's policy required interdisciplinary team assessment and physician orders for self-administration, but these procedures were not followed for the residents involved.