Failure to Ensure Proper Assessment and Orders for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents had appropriate physician's orders and assessments for self-administration of medications. In one instance, two suppositories and a bottle of lubricating eye drops were found at a resident's bedside and overbed table, respectively. The resident's medical record showed no physician's order for the suppositories or for medications to be kept at the bedside, and a prior assessment indicated the resident did not wish to self-administer medications. The resident had moderate cognitive impairment and diagnoses including constipation and chronic pain. In another case, a cup containing a yellow liquid medication was observed on a different resident's bedside table, which the resident stated was left by a QMA for later consumption. The QMA confirmed the medication was Cholestyramine and stated she did not need to remain with the resident until it was taken. The resident's record showed no assessment or order for self-administration, and the resident had moderate cognitive impairment, was dependent in ADLs and transfers, and had diagnoses including Parkinson's Disease and anxiety. Facility policy required an interdisciplinary assessment and physician order for self-administration, which was not followed in these cases.