Failure to Complete Self-Medication Administration Assessments
Penalty
Summary
The facility failed to ensure that self-medication administration assessments were completed for two residents who were permitted or requested to self-administer medications. For one resident with diagnoses including heart failure, diabetes, and anxiety disorder, the care plan noted non-compliance with medication administration, and the resident was observed with a cup of medications at bedside, specifically metformin from the previous night. Staff intervened and removed the medication, and review of the electronic health record revealed no documentation of a self-medication administration assessment for this resident. For another resident with multiple diagnoses including multiple sclerosis, paraplegia, seizure disorder, and severe allergies, there was an order for an EpiPen to be kept at bedside for self-administration in case of hypersensitivity reaction. Despite this, the resident reported not having the EpiPen available in the room and staff were unaware of the resident's allergies or the location of the EpiPen. The facility's records showed no completed self-medication administration assessment for this resident, even after the EpiPen was received. Facility policy required an interdisciplinary team determination before allowing self-administration, but this process was not documented for either resident.