Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medications, as required. The resident, who was admitted with diagnoses including type 2 diabetes and gastroesophageal reflux disease, had a physician's order for antacid medication. The resident was coded as cognitively intact on her most recent MDS assessment. However, there was no care plan or documented assessment for self-administration of medication in her medical record. During an observation, surveyors found multiple medications, including a partially used bottle of liquid bismuth, chewable antacids, and an unopened topical treatment, at the resident's bedside. The resident stated she took these medications when needed and had them delivered to her. Nursing staff confirmed that the resident was not assessed for self-administration and should not have had medications stored in her room. The assigned nurse was unaware of the presence of these medications and removed them upon discovery. The DON reported that the resident frequently ordered medications to be delivered and refused to allow staff to search her belongings. The DON also acknowledged that a self-administration assessment and a physician's order were required for the resident to self-administer medications, and that medications should be stored on the nurse's medication cart, not in the resident's room.