Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident was found to be self-administering Systane eye drops, despite not being assessed as able or willing to self-administer medications. During an observation, two bottles of Systane eye drops were found on the resident's bedside table, and the resident confirmed self-administration. A licensed vocational nurse (LVN) verified the presence of the medication at the bedside and stated that the resident was not able to self-administer the eye drops and should not have had them at the bedside. Review of the resident's medical record showed no physician's order for the Systane eye drops or for self-administration, and the care plan did not address the resident's eye condition or ability to self-administer medication. The facility's policy requires an assessment, physician's order, and care plan documentation for self-administration, none of which were present for this resident. The Director of Nursing (DON) confirmed that the necessary documentation and orders were missing.