Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that self-administration of medications was clinically appropriate for three residents. Specifically, the nursing staff did not complete required assessments to determine if these residents were capable and safe to self-administer their medications. In each case, there was no documentation of a self-administration evaluation assessment in the electronic medical record, and the residents' care plans did not address the safety or appropriateness of keeping medications at the bedside. For one resident with chronic obstructive pulmonary disease and respiratory failure, an albuterol inhaler was observed at the bedside on multiple occasions, but there was no physician's order allowing the resident to self-administer the medication or to keep it at the bedside. Another resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had eye drops at the bedside that were administered by a representative without a physician's order or assessment for self-administration. A third resident, cognitively intact but with significant physical limitations, kept Rolaids at the bedside and self-administered them without an order or assessment. Staff interviews confirmed that the required physician's orders and assessments for self-administration were missing for all three residents. Nursing staff acknowledged the lack of documentation and orders, and the director of nursing confirmed that residents with medications at the bedside should be evaluated for cognitive ability and clinical appropriateness, which had not been done in these cases.