Failure to Assess and Authorize Resident for Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including a left humerus fracture and cirrhosis of the liver was observed with a cup of pills left on her bedside table, which she indicated were her medications left by staff for her to take. The resident stated she would take the pills after eating, and an LPN confirmed that the medications were left at the bedside because the resident wanted to eat first. The LPN was unaware if the resident had been assessed for self-administration of medications and stated she was supposed to stay with residents while they took their medications. Review of the resident's clinical record revealed there was no assessment by the interdisciplinary team (IDT), no physician's order, and no comprehensive care plan authorizing self-administration of medications. The Care Services Administrator confirmed the absence of these required documents. Facility policy requires a Medication Self-Administration Evaluation, physician notification, and an order prior to allowing self-administration, none of which were completed for this resident.