Failure to Revise Care Plans for Medication Self-Administration
Penalty
Summary
The facility failed to revise the comprehensive care plans to include medication self-administration for two residents who were observed self-administering their medications. For one resident with chronic kidney disease, anemia, and cerebrovascular disease, records showed that the resident was permitted to apply a topical medication independently due to the private nature of the application site. However, there was no documentation in the care plan addressing the resident's ability or plan to self-administer this medication. The nurse confirmed that the resident applied the medication independently but did not indicate that an assessment or care plan update had been completed. For another resident with vascular dementia and asthma, the resident was observed self-administering an inhaler medication, taking more puffs than prescribed and not following proper inhaler technique. The nurse acknowledged that the resident self-administered the inhaler but did not ensure the resident followed the correct procedure or updated the care plan to reflect self-administration. Review of both residents' care plans revealed no inclusion of medication self-administration, despite staff statements and observations confirming that self-administration was occurring.