Failure to Assess and Authorize Safe Self-Administration of Medications
Penalty
Summary
A deficiency occurred when a resident was found to be self-administering medications, including acetaminophen, a stool softener, and a laxative, without an appropriate assessment or physician order authorizing self-administration. The resident reported taking acetaminophen every four hours for pain related to a recent shingles episode and kept these medications in her purse, which had been brought in by her daughter. The resident demonstrated knowledge of her medication regimen and showed the surveyor the medications in her possession. However, there was no documentation of an assessment for self-administration, no physician order permitting this practice, and the medications were not stored in a secure location as required by facility policy. Interviews with nursing staff confirmed they were unaware the resident had medications in her room and that no assessment or care plan for self-administration had been completed. Review of the resident's physician orders and medication administration record showed an order for acetaminophen with specific dosing instructions, but the resident was self-administering a different strength and frequency than ordered. Facility policy requires an interdisciplinary team assessment, physician order, care plan documentation, and secure storage for self-administered medications, none of which were in place for this resident.