Failure to Ensure Physician Orders and Assessments for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered medications had the required physician's orders and assessments in place. In one instance, a resident with heart failure and COPD was observed keeping and self-administering both eye drops and an inhaler at his bedside. Although the resident was cognitively intact and had physician's orders for the medications themselves, there was no order or assessment authorizing self-administration. Staff confirmed that neither the required assessment nor the order for self-administration was present in the resident's record. In another case, a resident with encephalopathy, dementia, and a history of opioid abuse, who was assessed as having severe cognitive impairment, was observed keeping and applying lidocaine patches independently. The resident had a physician's order for the medication but not for self-administration, and no assessment had been completed to determine if self-administration was clinically appropriate. Staff interviews confirmed the absence of the necessary documentation and assessments for both residents, despite facility policy requiring interdisciplinary team determination for safe self-administration.