Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
A deficiency occurred when the facility failed to assess a resident for self-administration of medications as required by its policy. The resident, who was admitted with a left arm and left lower leg fracture following a motor vehicle accident and was documented as cognitively intact, had several bottles of vitamins and eye drops on the bedside table. The resident reported that these items were brought in by family and had been self-administered for several weeks without staff intervention or assessment. Despite the facility's policy requiring an interdisciplinary team assessment and documentation before allowing self-administration of medications, no such evaluation was found in the resident's clinical record. Staff confirmed that the resident had been in possession of and using these medications without the required assessment or physician order. The deficiency was identified through observation, interview, and record review, with staff acknowledging the oversight in not completing the necessary evaluation.