Failure to Assess and Approve Self-Administration of Medications
Penalty
Summary
A resident with a history of hypertension and pulmonary embolism, and documented moderate cognitive impairment, was observed self-administering medications without the required assessment and approval from the interdisciplinary care planning team. The resident had an unlabeled transparent medicine cup containing two tablets, which she identified as Eliquis and Metoprolol, on her overbed table. She reported that a nurse had left the medications for her earlier so she could take them later. Review of the resident's clinical records by the Director of Nursing confirmed that there was no documented evaluation or care plan for self-administration of medications. Facility policy requires that residents may only self-administer medications if the attending physician and the interdisciplinary team have determined the resident has the decision-making capacity to do so safely. This policy was not followed in this instance.