Failure to Assess and Secure Medication for Resident Without Capacity
Penalty
Summary
A deficiency occurred when a resident's prescribed eye drops were found left on the bedside table without proper assessment or authorization for self-administration. The resident had been admitted with diagnoses including diabetes mellitus and chronic obstructive pulmonary disease, and a recent history and physical indicated the resident did not have the capacity to make decisions at the time. Despite this, the eye drops were accessible in the resident's room, and there was no documentation of a self-administration assessment, care plan, or physician's order permitting the resident to self-administer the medication. During observations and interviews, both a Licensed Vocational Nurse and a Registered Nurse confirmed the presence of the eye drops on the bedside table and acknowledged that the medication should have been stored securely in the medication cart. Both staff members also confirmed that there was no assessment or care plan in place for self-administration, and no physician's order had been obtained. The Director of Nursing further stated that a self-administration assessment, care plan, and physician's order are required for a resident to self-administer medication, and that medications should be stored in locked storage to prevent access by other residents. A review of the facility's policy on self-administration of medication indicated that the interdisciplinary team must assess a resident's cognitive, physical, and visual abilities before allowing self-administration, and that the assessment must be reviewed by the attending physician. In this case, these procedures were not followed, resulting in the medication being left unsecured and accessible to the resident and potentially to others.