Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the clinical appropriateness of self-administering medications, as required by policy. In the case of one resident with dementia and severe cognitive impairment, a prescription nasal spray was found at the bedside without an active order, completed self-administration assessment, or documentation in the care plan. The resident reported using the nasal spray independently, and nursing staff, including the RN, LPN, and DON, were unaware of the medication being kept at the bedside or of any assessment having been completed for self-administration. Another resident, who was cognitively intact, was observed with a medication cup containing a pill on the bedside dresser. The resident stated that a nurse had given the pill to be taken as needed and had kept it at the bedside for several days before self-administering it. There was no order for self-administration, no assessment completed, and no care plan documentation for self-administration of medications for this resident. Nursing staff and the DON confirmed that the resident was not approved to self-administer medications and that no assessment had been performed. Facility policy requires that residents requesting to self-administer medications must be assessed by a licensed nurse, reviewed by the interdisciplinary team, and, if approved, have a physician's order and a care plan in place. The policy also states that medications should not be left unattended at the bedside unless these steps are completed. In both cases, these procedures were not followed, resulting in unsupervised medication administration and lack of appropriate documentation.