Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess and authorize residents for self-administration of medications as required by policy and physician orders. One resident with a history of dysphagia, sepsis, severe protein-calorie malnutrition, and hypertensive heart disease, who was cognitively intact, was found with multiple medications at his bedside, which he reported using as needed for pain since admission. There was no physician order or care plan assessment permitting this resident to self-administer medications. The unit manager confirmed the medications were present and removed them, stating that the facility would need to administer the medications per physician orders. Another cognitively intact resident with multiple diagnoses, including muscle disorders, diabetes, sepsis, and COPD, was found with a medicine cup of pills on his nightstand. The resident stated a nurse had given him the cup of pills, and the nurse later acknowledged uncertainty about whether the resident was assessed for self-administration. There was no documentation of an assessment, physician order, or care plan for self-administration for this resident. Facility staff confirmed that assessments and orders were required but had not been completed, and they could not provide a list of residents authorized to self-administer medications.