Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team failed to ensure that a resident had a physician's order and a proper assessment for self-administration of medications left at the bedside. During a record review, it was found that the resident, who had diagnoses including atrial fibrillation, hypertension, neuropathy, osteoarthritis, and difficulty walking, was cognitively intact according to the Minimum Data Set. However, the resident required setup assistance for eating and oral hygiene. Observation of the resident's room revealed bottles of extra strength acetaminophen and Dulcolax in the bedside drawer, accessible while the resident was not present. Interviews with nursing staff confirmed that the resident did not have a physician's order to self-administer these medications, nor had an assessment been completed to determine the resident's capability to do so safely. The facility's policy requires that residents be assessed for cognitive and physical ability and have physician approval before self-administering medications, with such medications stored securely. The medications were not stored in a locked container, and staff acknowledged that this practice was not in accordance with facility policy.