Failure to Assess and Document Safe Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including cellulitis, chronic pain, and arthritis was observed to have medications, including Tylenol and a controlled substance (oxycodone), left at the bedside without direct supervision or confirmation of ingestion by nursing staff. The resident reported that nurses routinely left medications in the room, allowing the resident to take them at their discretion. Observations confirmed that a licensed nurse handed the resident a cup containing multiple medications, including a controlled substance and other critical medications, and then exited the room without verifying that the medications were taken. Record review revealed there was no documented assessment for the resident's ability to safely self-administer medications, nor was there a physician's order authorizing self-administration. The resident's care plan did not address self-administration of medications, and facility policy required physician and interdisciplinary team determination of a resident's capacity to self-administer. The Director of Nursing confirmed that nurses should not leave medications with residents and should observe ingestion, but this was not followed in the case of this resident.