Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to assess and properly authorize a resident for self-administration of medication, despite the presence of multiple medications at the resident's bedside. Facility policy required that residents requesting to self-administer medication undergo a safety assessment and interdisciplinary team review before being permitted to keep medications at bedside. However, the resident in question had medications including trazadone, Tylenol ES, Imodium, saline nasal spray, and Aspercreme at their bedside without any documented assessment, care plan intervention, or physician order allowing self-administration or bedside storage of these medications. The resident, who had a history of depression, GERD, and facial fractures, was cognitively intact and functionally independent according to the most recent MDS. The resident reported using trazadone at bedtime and Tylenol for pain, and expressed a desire to self-administer medication, but stated they had not been assessed for this ability by nursing staff. The care plan only directed staff to administer medications as ordered and did not address self-administration. Medication orders did not include permission for bedside storage or self-administration, and some medications present at the bedside were not listed in the active orders. Multiple staff members, including RNs and CNAs, reported being unaware of any medications at the resident's bedside and had not observed or reported them during their assigned shifts. When the medications were eventually discovered, staff acknowledged that medications should not have been present at the bedside without proper assessment and authorization. The DON confirmed that only one resident in the facility had been assessed and approved for self-administration, and it was not this resident.