Failure to Develop Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who was self-administering Imodium and probiotic oral tablets, both of which were stored at the resident's bedside. The resident had been admitted with diagnoses including a right foot fracture, age-related cognitive decline, and constipation. According to the Minimum Data Set, the resident was able to make herself understood, required assistance with eating and hygiene, and was dependent on staff for transfers. Physician orders specified that the resident could self-administer these medications, with the family providing the Imodium and both medications being kept at the bedside. During a review of the resident's records, including the Medication Administration Record and care plans, the Director of Nursing confirmed that there was no care plan addressing the resident's self-administration of medications. The facility's own policies required the interdisciplinary team to assess and document a resident's ability to self-administer medications and to include this information in the care plan. Despite these requirements, no such care plan was found for the resident, resulting in a failure to meet the facility's policy and regulatory standards for comprehensive care planning.