Failure to Assess and Document Resident Safety for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed and found safe to self-administer their own medications before allowing them to do so. Observations revealed that staff routinely left cups of medications at residents' bedsides or on meal trays, allowing residents to take their medications independently without direct supervision. In several cases, residents did not immediately take the medications, and some expressed uncertainty about the purpose of the medications or the conditions they were treating. Record reviews for the affected residents showed that there were no documented assessments for the safety of self-administration of medications, nor were there physician orders authorizing self-administration in the electronic health records (EHRs). Care plans for these residents did not reference their ability to self-administer medications or outline any monitoring procedures. For example, one resident with impaired cognitive function and another with a diagnosis of major depressive disorder and delusional disorders were both left to self-administer medications without documented evaluation of their capacity to do so safely. Interviews with staff revealed inconsistent understanding of the facility's procedures regarding self-administration of medications. While one staff member believed that no physician order or assessment was required, another stated that both were necessary, along with a risk/benefit discussion. The facility's own policy required an interdisciplinary team assessment, documentation in the medical record, and care plan updates for residents self-administering medications, none of which were found in the reviewed cases.