Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to implement its policy regarding self-administration of medications for one resident. Specifically, a resident with multiple diagnoses, including diabetes mellitus, peripheral vascular disease, obesity, hypothyroidism, and hyperlipidemia, was observed to have five medication bottles at his bedside. These included Simethicone Tablets, PB8 Probiotic, Maximum Strength Ultra-Zyme, and Say Yes to Beans. The resident stated that he used these medications for stomach issues. Review of the resident's Minimum Data Set indicated a BIMS score of 9, reflecting moderate cognitive impairment. Upon review, the DON confirmed that there was no physician's order, no assessment for self-administration, and no care plan developed for the resident to self-administer medications or to keep medications at the bedside. The facility's policy requires that the attending physician and the interdisciplinary care planning team determine a resident's capacity to self-administer medications safely before allowing self-administration. These steps were not followed, resulting in the deficiency.