Failure to Safely Administer Medication to Non-Authorized Resident
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, hypertension, anemia, and arthritis was assessed as cognitively intact and independent in activities of daily living, but had a care plan indicating impaired cognition and a Self Administration of Medications Assessment (SAM) stating she was not able to self-administer medications. Despite this, nursing staff routinely left levothyroxine at the resident's bedside for her to take on her own, without direct supervision and without a physician's order for self-administration. The resident reported that she sometimes dropped the medication on the floor and did not always inform staff, and staff confirmed they did not observe her taking the medication but assumed it was taken if it was no longer in the cup. The facility's policy required an interdisciplinary team assessment and a physician's order for self-administration of medications, neither of which were in place for this resident. Interviews with nursing staff and the DON confirmed that the expectation was for nurses to administer medications as ordered and not to leave medications at the bedside unless there was an order for self-administration. The failure to follow these procedures resulted in the resident self-administering medication despite being assessed as unable to do so safely.