Failure to Assess and Document Safety for Medication Self-Administration
Penalty
Summary
The facility failed to ensure that residents who self-administered medications were properly assessed for safety, as required. For one resident, a medication cup containing applesauce and several pills was observed on the bedside table. The resident explained that she needed her medications to dissolve in applesauce before swallowing, and staff would leave the cup with her for this purpose. However, her clinical record did not contain a physician's order for self-administration, and her Medication Self-Administration Safety Screen indicated she was not safe to self-administer medications, requiring staff presence during administration. There was also no care plan addressing medication self-administration for this resident. Another resident was found with medication pills on the floor and a medication cup on the bedside table. Staff removed the pills and cup, stating that medications should not be left in resident rooms and expressing uncertainty about how the pills ended up on the floor. This resident's clinical record also lacked a care plan for medication self-administration and did not include a Medication Self-Administration Safety Screen. Both residents were assessed as moderately cognitively impaired and had multiple medical diagnoses requiring complex medication regimens. Facility policy requires that only licensed or permitted staff administer medications unless the attending physician and interdisciplinary team determine a resident can safely self-administer. In both cases, there was no documentation of such determinations, and the required assessments and care planning for self-administration were missing, leading to the deficiency.