Failure to Prevent Unauthorized Medication Access and Self-Administration
Penalty
Summary
A deficiency was identified when razors and a medication inhaler were found at the bedside of a resident with moderate cognitive impairment and multiple medical diagnoses, including cerebrovascular disease, COPD, nicotine dependence, and anxiety disorder. The resident had a BIMS score of 12, indicating moderate cognitive impairment, and required varying levels of assistance with daily activities. There was no physician's order for self-administration of medications, nor was there any evidence in the care plan or medical record that the resident had been assessed or approved for self-administration of medications or treatments. The resident's most recent smoking evaluation also indicated unsafe smoking behavior. Interviews with staff confirmed that facility policy does not permit residents to self-administer medications or keep medications in their rooms without proper assessment and documentation. Staff members stated that if medications are found in a resident's possession, they are to notify a nurse or unit manager immediately. However, the inhaler remained at the resident's bedside, and at least one staff member observed it but did not report it, assuming the nurse was already aware. Review of facility policy confirmed that self-administration of medication requires interdisciplinary team approval and care plan documentation, which was not present in this case.