Failure to Assess and Authorize Resident Self-Administration of Topical Medications
Penalty
Summary
The facility failed to determine if a resident was capable of self-administering topical medications, as required by policy and clinical standards. A resident with moderately impaired cognition, as indicated by a BIMS score of 11, was observed with multiple unlabeled and labeled medication cups containing topical creams at his bedside, which he reported applying himself. The clinical record review showed that the resident had physician orders for several topical medications, including Triamcinolone, Diclofenac, and Hydrocortisone, but there was no physician order or documented assessment authorizing self-administration of these medications. The care plan noted the resident's preference to self-apply creams and lotions, but this intervention was added only after the issue was brought to the attention of the Director of Nursing. Staff interviews revealed a lack of awareness and oversight regarding the resident's self-administration of medications. One LPN stated she was responsible for applying the topical medications and was unaware the resident was self-administering them. The DON confirmed that the resident did not have an order or assessment for self-administration and acknowledged that medications should be kept in a secure place. Facility policy required a formal assessment of the resident's ability to self-administer medications and proper documentation, which was not completed in this case.