Failure to Reassess and Authorize Resident Self-Administration of Medication
Penalty
Summary
A resident with a diagnosis of gastroesophageal reflux disease (GERD) was admitted to the facility and had a physician's order for calcium carbonate chewable tablets to be taken as needed for GERD symptoms. The resident's self-administration assessment indicated she did not wish to self-administer medications, and her annual MDS assessment showed she was cognitively intact. Despite this, observations over several days revealed a bottle of antacid tablets at the resident's bedside, which the resident stated had been brought by a family member and that she took as needed for heartburn, particularly at night. Nursing staff were unaware that the resident had the medication at her bedside and that she was self-administering it. The nurse interviewed stated there was no order for the resident to self-medicate and did not believe the resident was able to administer her own medications. The Director of Nursing confirmed that residents must be assessed and have a physician's order to keep medications at bedside and self-administer, which had not occurred in this case.