Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, as required, for a resident with multiple diagnoses including dry eye syndrome and dry mouth. The resident was cognitively intact and independent with personal care, but there was no documented assessment, physician order, or care plan addressing self-administration of medications. Observations revealed that the resident had bottles of eye drops and mouth spray left at her bedside on multiple occasions, with faded or partially removed labels, and the resident was unable to state the purpose or frequency of the medications beyond general use for her eyes and mouth. The resident reported that nursing staff left the medications with her to self-administer and would later retrieve them. Interviews with staff confirmed that there was no order or assessment for the resident to self-administer medications, and that the facility's policy required such steps before allowing self-administration. A medication aide admitted to leaving the medications in the resident's room due to a stressful shift and forgetting to retrieve them, while the nurse and DON both acknowledged that medications should not be left with a resident without proper authorization and assessment. The administrator also confirmed that the required procedures for self-administration had not been followed in this case.