Failure to Assess and Authorize Safe Self-Administration of Medications
Penalty
Summary
The facility failed to complete required assessments and obtain physician orders to ensure the safe self-administration of medications for three residents with moderately impaired cognition. Observations revealed that medications, including controlled substances and topical treatments, were left at the bedside of these residents without proper authorization or documentation. In each case, there was no evidence of an interdisciplinary team assessment or a physician order permitting self-administration, as required by facility policy. One resident with a history of respiratory failure and a BIMS score indicating moderately impaired cognition was found with a medication cup containing six oral pills, including a controlled pain medication, and a high-calorie supplement at the bedside. Staff interviews confirmed that no assessment or physician order for self-administration existed for this resident, and the resident's care plan did not indicate a desire or ability to self-medicate. Another resident with dementia and a similar BIMS score was observed with a medication cup containing a white powder on the bedside dresser. Staff were unable to identify the substance, and there was no assessment or order for self-administration, nor any documentation of a related treatment. A third resident with heart failure and moderately impaired cognition was found with a tube of nystatin cream at the bedside, which the resident reported using daily. Staff confirmed there was no assessment or physician order for self-administration, and the medication was not documented in the medical record. Facility policy requires that residents may only self-administer medications if deemed safe and appropriate by the interdisciplinary team, with proper documentation and secure storage, none of which were followed in these cases.