Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) timely determined and documented whether self-administration of medications and treatments was clinically appropriate for two residents. For one resident with chronic obstructive pulmonary disease and other diagnoses, the clinical record showed she was cognitively intact and had multiple physician orders for daily medications. She was observed in her room with medication cups containing her morning medications left at her bedside without a nurse present. The resident confirmed she had not yet taken the medications. The nurse later confirmed the resident had taken them after being prompted. The Director of Nursing (DON) stated that while there was a self-medication assessment for the resident regarding lotion, there was no documentation supporting her ability to self-administer pill medications. For another resident with dementia who was also assessed as cognitively intact, multiple physician orders for daily medications were present. This resident was observed with a medication cup at his bedside and no nurse present. He could identify some, but not all, of the medications in the cup. The nurse reported that the resident refused to let her remove the medications from his room. The DON confirmed there was no self-administration assessment for this resident. The facility's policy requires an IDT assessment and physician order for self-administration, as well as secure storage and quarterly reassessment, none of which were documented for these residents.