Failure to Supervise Medication Administration and Assess for Self-Administration
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to supervise the medication administration for a resident who had not been assessed by the Interdisciplinary Care Team (IDT) for self-administration of medications. The resident, who had diagnoses including osteoarthritis, hypertensive urgency, and diabetes mellitus, was observed holding a cup with multiple medications at her bedside without a licensed nurse present. The LVN stated that the medications were left with the resident because she preferred to take them on her own, despite the absence of an IDT assessment or a physician's order permitting self-administration. Review of the resident's records showed that she required supervision or assistance for activities of daily living, such as eating and oral hygiene, and had no cognitive impairment. The medication orders included several drugs for blood pressure, diabetes, and other conditions, with specific administration times. The medications were scheduled for administration at a set time, but the LVN left them unattended at the resident's bedside, and the resident was not supervised during the process. Interviews with facility staff, including a CNA, RN, and the Director of Nursing (DON), confirmed that medications should not be left unattended and that an IDT assessment is required before a resident can self-administer medications. The facility's policy also requires an IDT evaluation to determine if self-administration is safe and appropriate. In this case, the required assessment and care planning had not been completed prior to the incident, and the medications were left with the resident without proper authorization or supervision.