Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to assess and authorize residents for self-administration of medications, as required by its own policy and regulatory standards. Four residents were observed with medications at their bedside or in their possession, including oral tablets, nutritional supplements, topical creams, and ointments, without documented assessments or physician orders permitting self-administration. In each case, the residents' care plans and electronic medical records did not reflect any evaluation or interdisciplinary team determination that self-administration was safe or appropriate. One resident with moderate cognitive impairment and multiple diagnoses, including dementia and hemiplegia, was found with both facility-supplied and personal Tums at bedside and reported taking them without staff supervision or documentation. Another resident with modified independence in cognitive skills had a cup of red liquid medication left at bedside for an extended period, with no recollection of whether it was taken, and no assessment or order for self-administration. A third resident with severe cognitive impairment had antifungal powder and a cream mixture at bedside, with no evidence of assessment for self-administration. A fourth resident, cognitively intact but with complex medical needs, kept multiple topical medications at bedside and self-applied them as needed, without knowledge of dosing limits and without documented authorization or assessment. Interviews with nursing staff confirmed that the facility's policy requires a physician order and a completed assessment before residents may self-administer medications. However, staff acknowledged that these steps had not been completed for the residents in question, and that medications other than moisture barriers should not be kept at bedside without proper authorization. The facility's own Self Administration of Medication Program outlines the need for interdisciplinary team review, physician order, and care plan documentation, none of which were present for the affected residents.