Failure to Assess and Document Resident's Self-Administration of Medications
Penalty
Summary
A deficiency occurred when a resident, admitted with a history of myocardial infarction and tachycardia and assessed as cognitively intact, was observed with multiple medications at their bedside. The resident reported that nursing staff would provide all their morning medications and leave them at the bedside, allowing the resident to sort and check the medications for accuracy before self-administering. Multiple observations confirmed the presence of various pills and nebulizer vials left within the resident's reach on several occasions. Facility policy requires that residents may only self-administer medications if the interdisciplinary care team, in conjunction with the attending physician, has determined and documented that the resident has the capacity to do so safely. The policy also mandates that such assessments be documented, that a physician's order be present, and that the resident's ability to self-administer be periodically re-evaluated. In this case, the resident's medical record did not contain a care plan or physician's order authorizing self-administration of all medications, nor was there documentation of an interdisciplinary team assessment for all medications, including the nebulizer. Interviews with facility staff confirmed that an assessment, physician's order, and care plan are required for self-administration of medications. The only available assessment was limited to Tylenol and Colace and did not include the resident's nebulizer or other medications. Despite this, staff continued to leave medications at the bedside, contrary to policy and without the necessary documentation or team assessment.