Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident admitted with a diagnosis of gastroesophageal reflux disease (GERD) was allowed to keep and self-administer Tums, an over-the-counter antacid, at bedside without a documented assessment of their ability to self-administer medication. Facility policy required that residents be specifically authorized by the attending physician and assessed for appropriateness before being permitted to self-administer medications. However, the resident was observed with a medication cup containing Tums at bedside and reported that staff provided the medication for use as needed, without supervision. Interviews with nursing staff and facility leadership confirmed that there was no physician order or completed assessment authorizing the resident to self-administer medication or to keep medication at bedside. Both the LPN and the Director of Health Services acknowledged that the required assessment had not been performed, and the Executive Director confirmed that medications should not be left at bedside without such an assessment. The failure to assess the resident's ability to self-administer medication and to follow facility policy led to the deficiency.