Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, resulting in the resident keeping several medications at her bedside without clinical evaluation or physician orders. The resident, who was moderately cognitively impaired and had diagnoses including non-Alzheimer's dementia and chronic pain syndrome, stored and self-administered arthritis cream with 25% capsaicin, arthritis pain relief gel with 2% menthol, chewable antacid tablets, and cough drops. There was no documentation in the medical record of an assessment for self-administration, no physician orders for these medications, and no care plan addressing self-administration. Multiple staff members, including a nurse, unit manager, nurse aide, DON, and the administrator, were unaware that the resident kept and used these medications at her bedside. The nurse reported applying arthritis cream from the medication cart, but was unaware of the resident's personal supply. The DON and administrator confirmed that no assessment for self-administration had been conducted and were unsure how the facility would have known about the medications at the bedside. The lack of assessment and oversight led to the deficiency.