Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
Facility staff failed to determine if a resident was safe to self-administer medications, as required by facility policy and regulatory standards. The policy stated that residents wishing to self-administer medications must have a physician's order and an evaluation to determine their capability. Review of the resident's clinical record showed no physician's order for self-administration, no documented evaluation of the resident's ability to self-administer medications, and no care plan addressing this issue. During an observation, the resident was found taking medications at her bedside without staff supervision. The medications included several tablets of varying shapes and colors. Interviews with nursing staff and the Nursing Home Administrator confirmed that the resident had not been evaluated for self-administration and did not have the necessary physician's order, and that medications should not have been left at the bedside.