Failure to Assess and Care Plan for Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents were properly assessed and care planned for self-administration of medications, as required by facility policy. One resident was found with three bottles of eye drops at her bedside, which she self-administered without a physician's order or a documented assessment by the interdisciplinary team (IDT) to determine her ability to safely self-administer these medications. The resident was not provided with education on the correct technique for administering the eye drops, as she reported not knowing how long to keep her eyes closed after application and often opened them immediately after use. Review of her medical record confirmed the absence of a physician's order and a care plan addressing self-administration of these medications, despite her having the capacity to make medical decisions. Another resident was observed with an antifungal powder at her bedside, which she reported possibly using once but could not recall who provided it. This resident's medical record indicated moderately impaired cognition, and there was no physician's order, assessment for self-administration, or care plan for the use of this medication. Staff interviews confirmed that the medication was not authorized to be kept at the bedside and that the resident and her family had not been educated on the facility's protocol regarding self-administration and storage of medications. Facility policy requires that residents may only self-administer medications if the IDT determines it is clinically appropriate and safe, with documentation in the medical record and care plan, and with periodic reassessment. Any medications found at the bedside without authorization are to be removed. In both cases, these procedures were not followed, resulting in unauthorized self-administration of medications without proper assessment, documentation, or education.