Failure to Assess Residents for Medication Self-Administration
Penalty
Summary
The facility failed to assess two residents for their ability to self-administer medications before allowing them to keep unsecured medications at their bedside. For one resident with diagnoses including Alzheimer's disease, psychotic disorder, and dysphagia, there was no care plan or assessment for self-administration of medication. Observations showed that this resident had a cup containing eight pills left on her overbed table while she was asleep, and staff confirmed that medications were sometimes left with the resident until she woke up, without a formal assessment or documentation supporting her ability to self-administer. For another resident, there was also no care plan or assessment for self-administration, yet prescription eye drops and antacid tablets were found unsecured in the room. The resident reported self-administering the eye drops and taking antacid tablets as desired, with staff confirming that the eye drops should not have been left in the room and that the resident did not have an order for the antacid tablets. The DON confirmed that this resident was not appropriate for self-administration and lacked the necessary assessment, and the Regional Nurse Consultant noted that the antacid tablets had been brought in by the family.