Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medication, as required by facility policy, for one resident with a history of rhabdomyolysis and moderate cognitive impairment. The resident was admitted with a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, and there was no care plan or physician's order in place for self-administration of medication or for keeping medication at the bedside. Despite this, a bottle of Tums, an over-the-counter antacid, was repeatedly observed on the resident's bedside table over several days. The resident reported that staff were aware of the medication and that a family member had provided it, and stated a desire to self-administer the medication as needed. Staff interviews revealed that neither the assigned CNA nor the LVN were aware of the medication at the bedside prior to the surveyor's observation, and both confirmed that no residents on the unit had orders to self-administer medications. The LVN acknowledged responsibility for conducting self-administration assessments and removed the medication upon discovery. The DON confirmed that an assessment and physician's order are required before a resident may self-administer medication or keep it at the bedside, and stated that no such orders were in place for any residents, including for over-the-counter medications. The administrator also stated that medication should not be left at the resident's bedside and expected staff to remove any such medications.