Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication as required by its policy. The policy states that each resident should be offered the opportunity to self-administer medications during routine assessment by the interdisciplinary team, and the results should be documented in the medical record. However, for one resident who was admitted to the facility and had a BIMS score of 15, indicating no cognitive impairment, there was no documentation of an assessment for self-administration of medication in the medical record. During an interview, the resident stated that they applied their own prescribed antifungal cream to their feet and that nurses had not applied it. Observation confirmed the presence of the ointment at the bedside, and photographic evidence was obtained. Despite this, the Treatment Administration Record showed that staff documented administration of the cream every shift, and there was a physician's order for staff to apply the medication. No interdisciplinary team assessment for self-administration was found in the record.