Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
A resident with a history of chronic respiratory failure, stroke with hemiplegia and hemiparesis, hypertension, and heart failure was observed with a cup of medications left at her bedside. The resident was cognitively intact and reported that a nurse had given her the medication but left it in the room when she stated she was not ready to take it. The resident was unsure of all the medications present in the cup, identifying only potassium among them. Review of the resident's medical record revealed no documentation of an assessment for self-administration of medications and no care plan addressing self-administration. Interviews with nursing staff confirmed that the resident did not have an order to self-administer medications and that medications should not have been left at the bedside. The nurse who left the medications was unaware of any self-administration assessment or order for the resident. Facility leadership, including the DON and Administrator, confirmed that no residents were currently authorized to self-administer medications and that facility policy required an assessment and physician's order before allowing self-administration. Despite this, medications were left unattended with the resident, contrary to facility policy and without proper assessment or authorization.