Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident did not self-administer medication without the required assessment or physician's order. According to facility policy, residents may self-administer medications only if the interdisciplinary team determines it is safe and there is a prescriber's order. Record review showed that the resident, who has diagnoses including diabetes and depression and demonstrated intact cognition, did not have an assessment for self-administration of medications, nor was there a physician's order or care plan addressing self-administration. Observation revealed the resident was left alone in their room with a cup containing multiple pills after a nurse handed them the medication and left. The resident reported that this was a recurring practice and that they had not taken the pills yet because they wanted to ask the nurse a question. The DON confirmed that the resident had not been assessed for self-administration, the interdisciplinary team had not made a determination, and there was no physician's order in place. The DON also stated that nursing staff are expected to observe residents taking their medications and not leave medications unattended.