Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) was involved in determining whether self-administration of medications was clinically appropriate for a resident. Specifically, a resident with diagnoses including a right foot fracture, age-related cognitive decline, and constipation was not assessed for self-administration of Imodium and probiotic oral tablets, which were stored at the resident's bedside. The resident's Minimum Data Set indicated some cognitive and physical limitations, including the need for assistance with eating, hygiene, and transfers. Despite this, physician orders allowed for unsupervised self-administration of these medications, and documentation in the Medication Administration Record (MAR) reflected this practice. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed that no assessment was completed to determine the resident's suitability for self-administration, and no documentation of such an assessment could be found in the resident's records. The facility's policy required the IDT to assess and periodically re-evaluate residents for self-administration, considering cognitive, communication, visual, and physical abilities, and to document the assessment in the chart. This process was not followed for the resident in question, resulting in a deficiency related to medication management and resident safety.