Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including hyperkalemia, end stage renal disease requiring dialysis, and chronic obstructive pulmonary disease was admitted to the facility and expressed a desire to self-administer medications. The resident had intact cognition but required maximum assistance with activities of daily living such as toileting, dressing, and personal hygiene. Despite the resident's request and ongoing self-administration of medications, including an inhaler and oral medication packets, the facility did not complete a self-administration assessment or obtain a physician's order as required by facility policy. Observations revealed that the resident kept multiple medications, including an inhaler and Lokelma packets, at the bedside and in an open dresser drawer. The resident reported independently using these medications, obtaining them from nursing staff as needed, and not having a lock box for secure storage. The resident stated that the nurse provided the inhaler for use as needed and that they had been self-administering Lokelma with each meal since admission. Interviews with facility staff, including the DNS, confirmed that no self-administration assessment had been completed for the resident and that the resident was not officially permitted to self-administer medications. Facility policy required a self-administration observation, a physician's order, care plan documentation, and secure storage for any medications kept at the bedside, none of which had been implemented for this resident prior to the survey findings.