Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A resident was observed on multiple occasions with a bottle of Tums at their bedside, indicating self-administration of medication. The clinical record review showed that the resident had diagnoses including cellulitis, diabetes mellitus, and obesity. The resident's Admission MDS assessment was incomplete, with sections on medication and functional abilities not filled out, though the resident was noted to be cognitively intact. There was no physician order for Tums or for self-administration of medication, and the comprehensive care plan did not address self-administration. A Self-Administration of Medication Assessment completed prior to these observations indicated that the resident did not wish to self-administer medications. The DON confirmed that no residents in the facility were authorized to self-administer medications. The facility's policy requires documentation and care planning for any resident deemed safe to self-administer medications, and mandates that unauthorized medications found at the bedside be removed. Despite these requirements, the resident continued to have access to Tums at the bedside without proper assessment, documentation, or authorization.