Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medications, as required by its own policy. The policy states that residents should be assessed for self-administration of medications upon admission, quarterly, annually, and with any significant change in condition. Review of the resident's record showed no documented evidence of such an assessment, despite the resident having a moderate cognitive impairment as indicated by a Brief Interview for Mental Status score of 11 on the most recent Minimum Data Set. Observations revealed that the resident had access to multiple medications at her bedside and in her bathroom, including an opened tube of Cloderm 0.1% cream, a bottle of pain relief roll-on with lidocaine hydrochloride 4%, and several tablets in medication cups. The resident confirmed self-application of the cream. Interviews with nursing staff and administration confirmed that the resident had not been assessed for self-administration and that medications should not have been left at the bedside or in the bathroom.