Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
Facility staff failed to assess a resident for the ability to self-administer medications before leaving multiple medications at the resident's bedside. During an observation, a resident was found with a cup containing various prescription and over-the-counter medications, including Plavix, gabapentin, Miralax, potassium, pramipexole, Eliquis, Lasix, and others, on her bedside table. The resident reported that staff did not observe her taking her medications except at night and was unaware of what medications were in the cup or their purposes. Review of the resident's care plan and medical record revealed no documentation or assessment indicating that it was clinically appropriate for the resident to self-administer medications or to have medications left at her bedside. Interviews with staff confirmed that medications were routinely left in the resident's room without a completed self-administration assessment or care plan authorization. Facility policy required staff to observe residents taking medications to ensure they were swallowed, which was not followed in this case.