Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
A resident with a history of Guillain-Barre syndrome, autonomic nervous system disorder, sixth nerve palsy, and chronic knee pain was observed in bed with several medications at the bedside, including Opcon-A eye drops, an expired tube of Pevisone topical cream, and a bottle of vitamin B-12 lozenges. The resident reported ordering these medications online and self-administering them as needed for eye and skin allergies, as well as taking vitamin B-12 daily. The registered nurse present confirmed there was no physician order for the resident to keep medications at the bedside or to self-administer them, and no assessment had been completed to determine if self-administration was clinically appropriate. Review of the resident's clinical records revealed no documentation of a physician order permitting bedside storage or self-administration of medication, nor evidence of a completed self-administration safety assessment. Additionally, laboratory results showed the resident's vitamin B-12 level was above the normal reference range. Facility policy requires a written physician order and assessment for residents to self-administer medications or store them at the bedside, but these steps were not followed in this case.