Failure to Assess and Supervise Self-Administration of Medications
Penalty
Summary
A resident with chronic kidney disease, anxiety, depression, and insomnia was admitted to the facility and assessed as cognitively intact with no behavioral issues. Despite this, there was no documentation in the resident's medical record indicating that an assessment had been conducted to determine the resident's ability to self-administer medications. Additionally, there was no care plan in place for self-administration of medications for this resident. During an observation, a medication aide was seen leaving a cup containing eight different medications on the resident's overbed tray, allowing the resident to take them at her discretion. The resident reported not knowing what the medications were or why she was taking them. The medication aide admitted to routinely leaving medications at the bedside without confirming if the resident had been assessed for self-administration and acknowledged this was not good practice. Both the DON and the Administrator stated their expectation that staff should remain with residents until all medications are consumed and that medications should not be left unattended.