Failure to Ensure Proper Authorization for Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had multiple diagnoses including cancer, neurogenic bladder, anxiety disorder, depression, and an unspecified mood disorder, was observed with a cup of vitamin gummies left at the bedside. The resident reported to an LPN that the number of gummies was inconsistent with what was expected, and the LPN acknowledged that she had not previously observed the resident taking the gummies. The LPN then stayed to observe the resident consume the gummies, which prompted the resident to question why observation was necessary, as it had not been done before. Further investigation revealed that there was no physician order in place for the resident to self-administer medication, nor had a Self-Administration of Medication Assessment been completed prior to the incident. The facility's staff confirmed that medications had been left at the bedside without the required physician order or assessment, and that these were only implemented after the surveyor's observation. The deficiency was identified due to the lack of proper authorization and assessment for self-administration of medication, resulting in unsupervised medication being left at the resident's bedside.