Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for their ability to safely self-administer medications. For three residents with moderate cognitive impairment and various diagnoses, including dementia, bipolar disorder, and gastroparesis, surveyors observed medicated powders and lotions at the bedside without documentation of a self-administration assessment in the health records. In each case, there was no evidence that the residents had been evaluated for their capacity to self-administer these medications, nor were there physician orders authorizing self-administration. Staff interviews confirmed that medications were present at the bedside and that facility policy required both a physician order and an assessment for self-administration. Staff acknowledged that these requirements had not been met for the residents in question, and that medications should not have been accessible to residents without proper evaluation. The lack of assessment and unauthorized access to medications constituted the deficiency identified by surveyors.