Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident with a medical history of a left knee infection related to an internal prosthetic was admitted to the facility and was alert and oriented upon admission. On the night of admission, the resident's son brought in home medications, including narcotics, because the facility did not have the resident's prescribed medications available. The resident and his son administered the medications, and the resident confirmed taking his own oxycodone. Nursing staff, including two LPNs, were aware that the resident was using medications brought from home, some of which were in an unlabeled container. One LPN attempted to verify the medications verbally with the resident but did not complete a self-administration of medication assessment and was unfamiliar with the facility's policy on self-administration. The other LPN, who admitted the resident, also did not complete the required assessment. Review of the clinical record revealed there was no documentation of a Self-Administration of Medication assessment or a physician order authorizing self-administration. Facility policy required an assessment to be completed for any resident requesting or engaging in self-administration of medication. The failure to assess the resident's ability to safely self-administer medications and to follow policy regarding verification and documentation led to the deficiency.