Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a proper assessment was conducted to determine if a resident was clinically appropriate to self-administer medications. According to facility policy, the interdisciplinary team is required to assess each resident's cognitive and physical abilities before allowing self-administration of medications, and this decision must be documented in the medical record and care plan. In the case reviewed, a resident over the age of 65 with diagnoses including GERD and osteoporosis, and who was cognitively intact but required moderate assistance with some activities of daily living, was observed to have a medication cup with a chewable tablet left at the bedside at her request. Nursing staff allowed the resident to keep the medication at her bedside and self-administer it, but there was no documentation of a formal assessment or a physician's order permitting self-administration. Interviews with nursing staff revealed that while some staff felt it was safe for the resident to self-administer the medication, they could not recall if a formal assessment had been completed. The DON confirmed that policy requires a self-administration assessment, physician notification, and care plan update, but acknowledged that no such assessment had been completed for this resident. Review of the electronic medical record confirmed the absence of documentation for a self-administration assessment or a physician's order for the resident to self-administer the medication.