Failure to Assess and Document Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team assessed and documented a resident's ability to self-administer medications as required by facility policy. A resident with diagnoses including deafness, pain, and atherosclerotic heart disease was found to have medications in their room and reported self-administering them. The resident was cognitively intact and independent with activities of daily living, but there was no documented evidence in the care plan or medical record that an assessment for self-administration of medications had been completed. Observations revealed that the resident took medications from a medication cup left at their bedside without nurse supervision, and pills remained unattended on the bedside table for extended periods. Interviews with staff confirmed that there were no current orders for self-administration and that medications should not be left at the bedside. The resident expressed awareness of their medication regimen and a preference for self-administration, but the required interdisciplinary assessment and documentation were not completed.