Failure to Assess and Authorize Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications, as required by its own policies and procedures. The resident, who was admitted with a diagnosis including Alzheimer's Disease and had a BIMS score indicating cognitive intactness, was observed on multiple occasions self-administering medications at her bedside. The resident reported that she typically takes her own medications at her own pace due to swallowing difficulties, with staff providing the pills for her to take. However, there was no documented assessment for self-administration in the resident's electronic medical record, nor was there a physician's order permitting self-administration, as required by facility policy. Staff interviews confirmed that medications were found at the resident's bedside and were subsequently removed and discarded by a Certified Medication Aide Technician, who stated that medications should not be left at the bedside. The Director of Nursing also confirmed that no assessment for self-administration had been completed for the resident. The facility's policies require a written physician order and approval by the interdisciplinary care team before a resident may self-administer medications, as well as an assessment of the resident's decision-making capacity. These steps were not followed in this case.