Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was comprehensively assessed for self-administration of medications. The resident, who had diagnoses including Type 2 diabetes mellitus, dermatitis, prurigo, and bipolar disorder, was noted to have intact cognition and required staff assistance with activities of daily living. The resident's care plan directed staff to administer medications per orders but did not include any direction or assessment for self-administration of medication. There was no provider order for lidocaine 4% gel or for self-administration, and the electronic health record did not contain an assessment for self-administration of medication. Observations revealed that a container of Tylenol lidocaine 4% was present and accessible in the resident's room, and the resident reported self-applying the medication for shoulder pain. Nursing staff observed the medication in the room on multiple occasions but did not remove it or address its presence. Interviews with staff confirmed that an assessment and provider order are required for self-administration, and that the medication should be documented in the medication administration record. The nurse manager and regional nurse consultant were unaware of the medication's presence and stated that staff are expected to act if such medications are found. The facility was unable to provide a policy for self-administration of medication.