Failure to Assess Resident Before Allowing Access to Medication at Bedside
Penalty
Summary
A resident with moderate cognitive impairment, as indicated by a Brief Interview for Mental Status score of 11, was found to have a tube of Voltaren gel at their bedside on multiple occasions. Review of the resident's records showed no physician order for self-administration of medications, no order for Voltaren gel, and no care plan addressing self-administration or bedside access to medications. The resident's electronic medication administration record documented that all medications were to be administered by facility staff. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the resident had not been assessed or care planned to self-administer medications and should not have had access to Voltaren gel. Despite this, the medication was observed at the resident's bedside on two separate days, indicating a failure to ensure the resident was properly assessed for safe self-administration prior to having access to the medication.