Failure to Assess and Document Resident's Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and authorized to self-administer medications. According to facility policy, residents must be evaluated for competency to self-administer medications, and the results must be documented in the resident's record and care plan. Additionally, a specific order for self-administration must be present in the medical record. In this case, a resident with diagnoses including irritable bowel syndrome, overactive bladder, and dysphagia was observed to be self-applying Aquaphor ointment and desitin cream for skin irritation and incontinence-related issues. The ointment was found in the resident's bathroom without a pharmacy label, and staff confirmed it was brought in by the family. Review of the resident's clinical record revealed there were no physician orders for the Aquaphor ointment, no orders or care plan for self-administration of medications, and no interdisciplinary assessment to determine the resident's competency for self-administration. The Director of Nursing confirmed that the required documentation and assessment were not present for this resident. These findings indicate the facility did not follow its own policies or regulatory requirements regarding self-administration of medications for one of five residents reviewed.