Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A resident with diagnoses including impaired mobility, impaired activities of daily living, left hemiparesis, and dysphagia was observed self-administering Metamucil mixed with orange juice at their bedside. The medication was left at the bedside, and the resident consumed it at their own pace without direct observation by nursing staff. The resident was not assessed or approved for self-administration of medication, and there was no physician's order, care plan, or interdisciplinary team documentation authorizing self-administration. The facility's policy required an assessment and care plan before allowing bedside medication storage and self-administration, which was not followed in this case. Nursing staff acknowledged that the resident could not open the medication packet independently and did not consume the medication in a timely manner. The nurse manager confirmed that the resident had not been assessed for self-administration capability and that the medication was left at the bedside without ensuring the full dose was taken. The lack of assessment and authorization for self-administration, combined with the resident's medical conditions, resulted in a failure to appropriately administer medication as required by facility policy.