Failure to Assess and Obtain Orders for Resident Self-Administration of Medications
Penalty
Summary
The facility failed to obtain evaluations and provider orders for residents to self-administer medications for four residents. Observations revealed that one resident was using a nebulizer independently without a documented self-administration evaluation or provider order, despite having an active medication order for inhaled treatment. Another resident was observed with a cup of pills left at the bedside, taking medications at his own pace due to swallowing issues, but without an assessment or physician order for self-administration. A third resident with severe cognitive impairment, as indicated by a BIMS score of 7, was found with unsupervised medications at her table and no documented assessment for safe self-administration. The fourth resident brought a bag of assorted, non-facility packaged pills to the nurse, and staff were unaware of their origin; this resident also lacked a provider order for self-administration. Interviews with staff confirmed that the required interdisciplinary team evaluations and provider orders for self-administration were not present for these residents. Facility records and a list of approved residents for self-administration did not include the four residents in question. Documentation review further showed that the necessary assessments and orders were missing from both the electronic health records and paper charts for these individuals.