Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
A resident with diagnoses including chronic obstructive pulmonary disease, hypertension, anemia, major depressive disorder, anxiety disorder, and sepsis was found to be self-administering her own eyedrops without a physician's order, assessment, or care plan documentation supporting self-administration. The resident, who was cognitively intact, kept a bottle of Refresh eyedrops at her bedside and reported using them independently each morning and night since admission. Staff were aware of the resident's self-administration, but no formal assessment or authorization was present in the medical record. Upon review, it was confirmed by nursing staff that there were no physician's orders for the eyedrops or for self-administration, nor was there any documentation of an assessment or care plan addressing this practice. Facility policy requires an interdisciplinary team assessment and a physician's order before a resident may self-administer medications, as well as proper documentation and storage arrangements. The lack of assessment and documentation led to the deficiency cited in the report.