Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for their ability to self-administer medications, as required by facility policy. Both residents had moderate cognitive impairment, as indicated by their Brief Interview for Mental Status scores. Despite this, there was no documented evidence in their medical records or care plans that an interdisciplinary team had evaluated or approved them for self-administration of medications. Facility policy states that such an assessment and documentation are necessary before allowing residents to self-administer any medications. Observations revealed that both residents had various topical medications and eye drops at their bedsides, which they reported using independently. One resident had multiple muscle rubs and creams, while the other had a tube of Aspercream and a bottle of eye drops, both of which were used regularly without staff oversight. Interviews with facility staff confirmed that there was no documentation of assessment or approval for self-administration for these residents, and that medications, whether over-the-counter or prescribed, should not be left at the bedside without proper evaluation.