Failure to Assess and Secure Medications for Self-Administration
Penalty
Summary
A deficiency occurred when a resident with a history of encephalopathy, type 2 diabetes mellitus, anxiety disorder, depressive episodes, hypertension, and dementia was found to have medications left at their bedside without proper assessment for self-administration. The resident's care plan indicated cognitive impairment and a need for assistance and reminders, and the Minimum Data Set (MDS) showed moderately impaired cognition with partial to moderate assistance required for personal hygiene. Despite these factors, two medications—hydrocortisone cream and vapor rub—were observed on the resident's bedside table during a survey observation. Interviews with staff revealed that there was no prior self-medication evaluation for the hydrocortisone cream, and the medication was left in the resident's room without a physician's order or interdisciplinary team assessment for self-administration. The LPN present was unaware that the medications were in the room and stated that she would take steps to label and obtain an order for the medication only after the surveyor's observation. Facility policy requires that medications be administered as prescribed and that self-administration is only permitted after an interdisciplinary team determines it is clinically appropriate and safe. The DON confirmed that the process for self-administration includes obtaining a physician's order, conducting an evaluation, and updating the care plan, and that medications should not be left at the bedside unless these steps are completed. The LPN also stated that medications should not be left at the bedside without an order for self-administration, citing safety concerns. The failure to assess the resident's ability to self-administer hydrocortisone cream and to secure the medication as per policy led to the deficiency.