Failure to Complete Required Self-Administration Assessment Before Allowing Resident to Self-Administer Medication
Penalty
Summary
A resident who was assessed as cognitively intact had a provider order for Nystatin antifungal powder to be applied to both breasts and groin folds every 12 hours as needed. During observation, an RN dispensed the antifungal powder into a medication cup and handed it to the DON, who then placed the cup on the resident's bedside table and left the room. The DON stated that the resident would apply the powder herself when ready. However, there was no documentation of a self-administration of medication (SAM) assessment for this resident. Interviews with nursing staff confirmed that a SAM assessment is required to determine if a resident is safe to self-administer medications and that a provider order is necessary for medications to be left at the bedside. Both the RN and ADON acknowledged that no current residents had a SAM assessment on file, and that such assessments are reviewed every three months for safety. Facility policy also requires specific authorization and assessment before allowing residents to self-administer medications, but this process was not followed in the case of the resident observed.