Failure to Assess, Monitor, and Care Plan for Medication Self-Administration
Penalty
Summary
The facility failed to ensure that residents with physician orders for self-administration of medications were properly assessed, monitored, and care planned for this practice. Four residents with orders to self-administer medications were not consistently evaluated by the interdisciplinary team for their ability to safely self-administer, and their care plans did not include interventions or focus areas related to medication self-administration. In several cases, documentation of assessments was missing, outdated, or not present in the residents' electronic medical records, and care plan meetings did not reflect discussion or planning for self-administration. Observations revealed that residents were storing medications in unsecured locations, such as unlocked dresser drawers or on top of bedside tables, and in some cases, residents possessed medications that were not ordered for self-administration. For example, one resident had two medications in his possession without physician orders for self-administration and reported difficulty applying a topical medication to an area not specified in the physician's order. Another resident was found with over-the-counter eye drops not prescribed by the facility physician and was unable to articulate the appropriate use of the medication. Interviews with staff, including the DON and nursing staff, indicated a lack of consistent verification and documentation regarding whether self-administered medications were actually being taken as ordered. Staff reported that there was no process for documenting self-administration on the MAR, and verification of administration was not routinely performed. The DON was unaware of these gaps in practice and acknowledged that care plans should include planning for self-administration of medications. The facility's policy required that the interdisciplinary team and physician determine a resident's capacity for self-administration, but this was not consistently implemented.