Resident Self-Administers Magnesium Supplement Without Physician Order
Penalty
Summary
A deficiency was identified when a resident was found to be self-administering a magnesium supplement without a physician's order. Facility policy requires that all medications, including supplements, be administered according to prescriber orders, and that residents may only self-administer medications if the attending physician and the interdisciplinary care planning team have determined the resident has the capacity to do so safely. Review of the resident's clinical record showed no order for magnesium, and there was no documentation that the resident had been assessed or approved to self-administer this supplement. During a medication pass observation, a licensed nurse was seen administering morning medications to the resident, and a bottle of magnesium gummies was observed on the resident's table. The resident stated she takes the gummies twice daily, and the nurse confirmed there was no order for this supplement and was unaware the resident was consuming it. This failure to ensure medications and supplements were administered according to policy and prescriber orders resulted in a significant medication error for the resident.