Failure to Assess and Authorize Medication Self-Administration
Penalty
Summary
The facility failed to ensure that medication self-administration was clinically appropriate and did not honor a resident's right to self-administer medications. A resident with multiple diagnoses, including polyneuropathy, hypertension, major depressive disorder, anxiety disorder, binge eating disorder, and intellectual disabilities, was observed with medications left at the bedside for self-administration. The resident had previously been assessed as not wanting to self-administer medications and not being a candidate for safe self-administration. Despite this, a nurse left several medications at the bedside at the resident's request, without conducting a new assessment or obtaining a physician's order for self-administration. The resident was able to communicate effectively and had the capacity to make decisions, as documented in the medical record. During an interview, the resident confirmed that the medications belonged to them and that the nurse left them at the bedside because the resident preferred to take them one at a time. The nurse confirmed leaving the medications for the resident to self-administer, stating that the resident was alert and often requested this arrangement. However, the nurse acknowledged that the facility's process required an assessment and a physician's order before allowing self-administration, neither of which were completed in this case. Further review and interviews with facility staff, including the RN and DON, confirmed that the facility's policy required an interdisciplinary assessment and physician's order before permitting self-administration of medications. The staff recognized that the process was not followed when the nurse left medications at the bedside without proper assessment or documentation. Facility policies also specified that medications should not be left unattended at the bedside unless authorized, and that residents' rights to self-administer medications must be supported by a clinical determination of safety and appropriateness.