Failure to Assess and Care Plan for Resident Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the safe self-administration of medication, specifically Cepacol Extra-Strength Sore Throat Benzocaine lozenges, which were found at the resident's bedside. Observation and interview revealed that the resident kept the medication in a duffle bag on her bed and used it during trips to the dialysis center for throat dryness. Despite the resident's capacity to understand and make decisions, as documented in her history and physical examination, there was no evidence in the medical record that the interdisciplinary team (IDT) had conducted an assessment of her ability to self-administer medications. Additionally, there was no physician's order authorizing the resident to self-administer the lozenges, nor was there a care plan developed to address this practice. The facility's policy requires an IDT assessment, a physician's order, and a care plan before a resident is permitted to self-administer medication or keep medication at the bedside. Staff confirmed that these steps had not been completed for this resident, and therefore, the medication should not have been accessible at the bedside.