Failure to Complete Self-Administration Assessment and Orders for Bedside Medications
Penalty
Summary
The facility failed to ensure that a complete self-administration of medications (SAM) assessment was performed and appropriate orders were obtained for all medications kept at bedside for one resident. The resident, who was alert, oriented, and largely independent in activities of daily living, was observed with three bottles of over-the-counter (OTC) medications at her bedside, including Hair, Skin, and Nail Vitamins, Elderberry Gummies, and Glucosamine/Chondroitin and MSM supplement. While the care plan and medical record documented a SAM assessment for elderberry chews, there was no assessment or provider order for the other OTC medications at bedside. The care plan directed staff to monitor bedside medication usage and assess the resident's capability to self-administer, but this was only documented for the elderberry chews. The resident had a complex medical history, including chronic pain, osteoporosis, and a recent femur fracture, and was receiving multiple prescribed medications for pain management. The DON confirmed that she was unaware of the additional medications at bedside and acknowledged that each medication kept at bedside required a separate SAM assessment and provider order, as per facility policy. The facility's policy required interdisciplinary team determination and documentation for safe self-administration, with periodic reassessment, but this process was not followed for all medications observed at the resident's bedside.