Failure to Assess and Care Plan for Resident Self-Administration of Medication
Penalty
Summary
A deficiency was identified when a resident was found to be self-administering Alphagan eye drops without the necessary clinical safeguards in place. The resident had two bottles of the medication in the bedside drawer and reported self-administering the drops since admission. Review of the resident's medical record revealed there was no physician's order for the medication, no assessment to determine the resident's ability to self-administer, and no care plan addressing self-administration. The facility's policy requires that residents be informed of their right to self-administer medications and that appropriate assessments and care plans be completed. Interviews with facility staff, including an LVN, the ADON, and the DON, confirmed that medications must have a physician's order, a self-administration assessment, and a care plan before a resident can self-administer. Staff verified that none of these requirements were met for the resident in question. The absence of these safeguards meant the resident was self-administering medication without documented clinical oversight or planning.