Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
The facility's interdisciplinary team failed to ensure that a resident was properly assessed and determined capable of self-administering medication that was left at the bedside, and did not obtain a physician's order for self-administration. The resident, who had diagnoses including atrial fibrillation, hypertension, congestive heart failure, type 2 diabetes, and peripheral vascular disease, was found to have a tube of triamcinolone acetonide cream at the bedside. The resident reported using the cream for itching and stated it was prescribed by a physician, but later indicated that a family member had brought the cream to the facility. Staff interviews revealed that the LVN was unaware of the medication at the bedside and confirmed there was no physician's order for self-administration. The DON stated that medications should only be kept at the bedside if the resident has been assessed as capable and has a physician's order, and that such medications should be stored in a locked container. Facility policy requires assessment by the IDT and a physician's order before allowing self-administration, with medications to be kept securely. These procedures were not followed in this instance.