Failure to Complete Assessment and Obtain Order for Self-Administration of Medication
Penalty
Summary
A resident with intact cognition and diagnoses including atrial fibrillation, heart failure, respiratory failure, cataracts, and glaucoma was observed to have prescribed eye drop medications left at their bedside for self-administration. The resident's medical record did not contain evidence that a self-administration of medication (SAM) assessment had been completed, nor was there a provider order authorizing the resident to self-administer medications. During medication administration, an LPN left one of the resident's prescribed eye drops on the bedside table and later confirmed that the resident did not have an order to self-administer medications. Interviews with staff, including the DON, confirmed that facility policy requires a SAM assessment and a physician order before residents are permitted to self-administer medications. The DON acknowledged that these steps had not been completed for the resident in question, and that medications should not be left at the bedside without proper assessment and orders. Facility policy also specifies that the ability to self-administer medications must be care planned with interventions specific to the individual resident.