Failure to Assess and Authorize Medication Self-Administration
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had multiple diagnoses including chronic respiratory failure, dementia, functional quadriplegia, and a history of swallowing difficulties, was found with a cup of liquid medication at her bedside. The resident explained that the nurse had left the medication and a supplement for her to take later, at her request. The assigned RN confirmed leaving the medication at the bedside and was unable to confirm if there was an order for self-administration. The medication, Lactulose Solution, was documented as administered earlier in the morning, but was still present at the bedside hours later. Review of the resident's medical record revealed there was no assessment for self-administration of medications, no physician's order authorizing self-administration, and no care plan addressing self-administration. Facility policy required physician authorization and specific procedures for self-administration, which were not followed in this case. The incident was acknowledged by the Director of Nursing, who confirmed that medications should not have been left at the bedside without proper authorization and assessment.