Failure to Secure Medications and Assess Resident for Self-Administration
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly secured and that only authorized personnel had access to them. A resident with diagnoses including peripheral vascular disease, type 2 diabetes, and congestive heart failure was observed with two tubes of clotrimazole one percent cream on his bedside table, which he self-applied for tinea corporis on his forearms. There was no assessment in the resident's medical record indicating that he was safe to self-administer medication, nor was there an order permitting self-administration of the antifungal cream. Staff interviews confirmed that the resident did not have authorization or an assessment for self-administration, and the prescribed medication was accessible at the bedside. Facility policy required an interdisciplinary assessment and a specific order for self-administration, which were not present in this case. The LPN removed the medication from the resident's room after observing the resident applying the cream himself.