Failure to Assess and Document Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the ability to self-administer medication, as required by facility policy and regulatory standards. A female resident with diagnoses including cancer, arthritis, Alzheimer's disease, and rheumatoid arthritis, and a BIMS score indicating moderate cognitive impairment, was allowed to keep a compounded oral medication at her bedside. There was no documentation in her care plan or medical record indicating that an assessment for self-administration safety had been completed, nor was there evidence that she had been instructed in the proper use of the medication. Observations revealed that two unsecured prescription bottles of the medication were present on the resident's nightstand, with no medication measuring cups or locked storage available. The resident reported that she took the medication several times a day by taking swigs, without measuring, and had not received any education on its use beyond the instructions on the bottle. Interviews with staff, including an LVN, DON, ADON, and Nurse Practitioner, confirmed that there was no knowledge of an assessment being completed prior to allowing bedside storage and self-administration, and that the resident had not been educated on the medication's use. Review of the facility's policy on bedside medication storage indicated that a written order, care plan documentation, assessment of self-administration skills, and resident education are required before permitting bedside storage and self-administration. None of these requirements were met for this resident, as evidenced by the lack of assessment, education, and appropriate storage, as well as the absence of documentation in the care plan and medical record.