Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A resident was observed lying in bed with two medicine cups on the over-bed table, one containing a single pill and the other containing seven pills. The resident stated that the medications had been there for some time and believed they included gabapentin, a muscle relaxer, and cholesterol medications, but was unsure about the identity of the other pills. There were no nursing staff present in the room at the time of observation. The resident's clinical record indicated cognitive intactness and diagnoses including hypertension, diabetes, hyponatremia, and depression. Upon review, the clinical record did not contain an assessment for the resident to self-administer medications, nor was there a physician's order permitting self-administration. Interviews with facility staff confirmed that a physician's order and an assessment are required for residents to self-administer medications, and that the resident in question did not have such authorization. Facility policy also requires an interdisciplinary team approval and a physician order for self-administration, which were not present in this case.