Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident with diagnoses including Parkinson's disease and acid reflux, and documented moderate cognitive impairment, was observed to have a bottle of Tums chewable tablets at their bedside and reported taking the medication as needed. Multiple observations confirmed the ongoing presence of the Tums on the resident's overbed table over several days. The resident's medical record included a provider order for Tums to be taken as needed, but there was no documentation of an order permitting self-administration, nor was there an assessment indicating the resident's ability to safely self-administer the medication. Additionally, the Medication Administration Record for the relevant month did not reflect any administrations of Tums. Facility staff confirmed that residents wishing to self-administer medications are required to have a provider assessment, an order, and a completed self-medication assessment, none of which were present for this resident. The lack of assessment and documentation meant the resident was self-administering medication without the necessary clinical evaluation or oversight.