Failure to Assess and Authorize Resident for Medication Self-Administration
Penalty
Summary
A resident was observed alone in her room with eight pills in a disposable medication cup placed next to her meal tray. The medications had been provided by an LPN prior to breakfast, but the resident had not yet taken them, and no staff were present in the room or nearby. The LPN later confirmed she had given the medications to the resident and was unaware they had been left unattended. Upon discovering the situation, the LPN removed the medication cup containing buspirone, duloxetine, ferrous gluconate, furosemide, lisinopril, metformin, metoprolol, and Tylenol from the resident's room. Review of the resident's record revealed that no medication self-administration assessment had been completed, and there was no physician order authorizing self-administration. The facility's policy requires a self-administration evaluation and physician authorization before a resident is permitted to self-administer medications. The resident was cognitively intact according to a recent mental status score, but the required assessment and documentation were not in place, resulting in the resident being left alone with medications contrary to facility policy.