Failure to Assess and Document Resident's Ability for Self-Administration of Medications
Penalty
Summary
The facility failed to have the interdisciplinary team (IDT) determine and document whether self-administration of medications was clinically appropriate for a resident. The resident, who had diagnoses including hypertension and was assessed as cognitively intact, had multiple physician orders for medications such as magnesium oxide, diltiazem, a calcium supplement, carboxymethylcellulose sodium eye drops, and metoprolol. During a medication administration observation, a Qualified Medication Aide (QMA) prepared the resident's medications and placed them on the bedside table, allowing the resident to take them without direct supervision. The QMA confirmed that the resident was able to take her medications independently. However, the Director of Nursing (DON) stated that the resident had not been assessed by the IDT to determine if she could safely self-administer her medications. The facility's policy requires that each resident who desires to self-administer medication must be assessed by the IDT for cognitive, physical, and visual ability, and that this assessment be documented. In this case, the required assessment and documentation were not completed prior to allowing the resident to self-administer medications.