Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident was found with a bottle of artificial tears eye drops on their bedside table, which had been left there by a medication nurse three days prior. The resident attempted to self-administer the medication but was unable to do so. There was no documentation in the resident's medical record indicating that an assessment had been completed to determine if self-administration of medication was clinically appropriate or safe for the resident, as required by the facility's policy and procedure. The policy specifies that the interdisciplinary team (IDT) must assess a resident's cognitive and physical abilities before allowing self-administration of medication. Further review of the resident's medical record confirmed the absence of an assessment or a physician's order authorizing self-administration of the eye drops. Both a licensed vocational nurse (LVN) and the assistant director of nursing (ADON) verified that the medication should not have been kept at the bedside and acknowledged that the required assessment and order were missing. The resident had the capacity to make medical decisions, as documented in their history and physical examination, but the necessary steps to ensure safe self-administration were not followed.