Failure to Assess and Care Plan for Resident Self-Administration of Medication
Penalty
Summary
A deficiency occurred when the facility failed to assess and care plan for a resident to self-administer medications. The resident, who had diagnoses including heart failure, diabetes, and shortness of breath, was noted to have intact cognition with a BIMS score of 14 out of 15. The care plan addressed diuretic therapy for hypertension, and the medication administration record showed an order for bumetanide 1 mg twice daily. During observation, the resident was found with a pill in a medication cup at the bedside and stated it was a pill to make him urinate, indicating he had access to the medication before staff ensured it was taken. Staff interview confirmed that the LPN checked on the resident and verified the pill was taken after the fact. However, the clinical record did not contain documentation that the resident was assessed as safe to self-administer medications. Facility policy requires that residents may only self-administer medications if the attending physician and the interdisciplinary care planning team determine the resident has the decision-making capacity to do so safely. This process was not documented for the resident involved.