Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A resident, who was cognitively intact according to the Minimum Data Set, was observed self-administering Aspercreme Lidocaine Liquid Roll-On to his right hip without a physician's order for the medication or for self-administration. The resident confirmed during an interview that the applicator belonged to him and that he applied it himself. Review of the clinical record by nursing staff confirmed there was no physician order for the Lidocaine Liquid Roll-On or for self-administration, although there was an existing order for a different form of lidocaine (patch) to be applied to the same area. Further review of the resident's clinical record revealed that there was no assessment completed for self-administration of medication, as required by facility policy. The policy states that an interdisciplinary team must determine and document which medications may be safely self-administered by a resident, with the results recorded in the medical record. Despite the resident later receiving a physician order for self-administration of a lidocaine cream, there was still no documented assessment for self-administration in the record.