Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the self-administration of Visine eye drops, as required by facility policy. The resident, who had diagnoses including bipolar disorder, unspecified dementia, and anxiety disorder, was found to have three bottles of Visine eye drops at her bedside and reported using them daily. However, she was unable to state how often she should use the drops. The physician's order for the eye drops did not specify that the resident was permitted to self-administer the medication, and there was no documentation in the medication administration record indicating that staff had administered the drops. Additionally, the resident's electronic medical record did not contain an assessment for self-administration of the eye drops. Staff interviews confirmed that the resident was allowed to keep the eye drops unsecured at her bedside and self-administer them without a documented assessment or a physician's order authorizing self-administration. The facility's policy required an interdisciplinary team assessment to determine if self-administration was clinically appropriate and safe, as well as secure storage of medications. Despite these requirements, the resident was permitted to self-administer the medication without the necessary assessment or authorization, and the medication was not securely stored.