Failure to Complete Self-Medication Assessment Prior to Resident Self-Administering Insulin
Penalty
Summary
A deficiency occurred when the facility failed to complete a self-medication assessment for a resident with type 2 diabetes mellitus, paraplegia, and spina bifida, who was observed self-administering insulin. The resident had an intact mental status, as indicated by a BIMS score of 15 out of 15, and was receiving insulin injections daily. During an observation, a registered nurse prepared the resident's insulin pen, and the resident independently cleaned the injection site and administered the insulin, while the nurse supervised and disposed of the needle. Review of the resident's care plan and electronic health records revealed no documentation of a self-medication assessment or identification of the resident's request to self-administer insulin. Staff interviews confirmed that no assessment had been completed prior to the resident self-administering medication, despite facility policy requiring an interdisciplinary team determination and documentation of safety and appropriateness before allowing self-administration. The care plan also lacked interventions addressing the resident's self-administration of insulin.