Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team failed to evaluate and assess a resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate. The resident, who had diagnoses including delusional disorder, diabetes, severe visual impairment, and anemia, was observed with five bottles of vitamin supplements at her bedside. The resident stated she had been taking the vitamins herself for years and was aware of their presence at her bedside. During interviews, staff members, including an LVN and the DON, confirmed there was no assessment or evaluation by the IDT or physician to determine if the resident was appropriate to self-administer supplements, nor was there a physician's order for self-administration. Record review showed that the resident required varying levels of assistance with activities of daily living and had episodes of incontinence. The facility's policy required an IDT assessment and documentation for residents to self-administer medications, as well as ongoing review by nursing staff. However, there was no documentation of any assessment or evaluation for this resident regarding self-administration of medications, and nursing staff were unaware of the supplements at the bedside. The facility's failure to follow its own policy and procedures resulted in the resident self-administering supplements without proper evaluation or oversight.