Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident's capability to self-administer medications as required by its own policy. According to the policy, an interdisciplinary team must determine which medications may be safely self-administered, and this assessment must be documented in the resident's medical record. For one resident with diagnoses including limitation of activities due to disability, Ehlers-Danlos Syndrome, and anxiety disorder, there was no documentation of such an assessment for several medications, including Fluticasone nasal spray, artificial tears, saline nasal spray, and gummy vitamins. Observations revealed that these medications were left unsecured in the resident's room, and the resident reported self-administering them daily. Clinical record review confirmed the absence of documentation regarding an assessment for self-administration. The DON confirmed that the required assessment had not been completed for this resident, which was not in accordance with facility policy.