Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered medications were properly assessed for their ability to do so safely and did not obtain the required physician's orders for self-administration, as outlined in facility policy. Four residents were identified as self-administering medications, including inhaled treatments, topical creams, and oral medications, without documented assessments or care plan interventions addressing their ability to self-administer. In several cases, medications were left at the bedside or in resident rooms without proper labeling or documentation, and some medications were expired or not prescribed for current use. One resident with moderate cognitive impairment was observed self-administering nebulizer treatments and using topical medications left at his bedside, including an expired antibiotic ear drop that he used for itching. He also had an antacid medication left at his bedside for self-administration without a physician's order or assessment. Another resident, who was cognitively intact, self-administered prescription cream and powder with physician's orders to keep the medications in his room, but there was no documentation of an assessment for his ability to self-administer these medications, nor was this addressed in his care plan. Additional residents were found to have medications such as Vicks Vapor Rub and nebulizer treatments in their rooms, which they self-administered without physician's orders or documented assessments. Facility staff, including LPNs and the DON, confirmed that no residents had been formally assessed for self-administration of medications and that physician's orders for self-administration were not in place. The facility's policies required both an assessment and a physician's order for self-administration, but these procedures were not followed, and the care plans did not address self-administration or medication storage for the affected residents.