Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident's capability to self-administer medications as required by its own policy. The policy states that residents must be evaluated for self-administration, require a physician's order, and, when applicable, be provided with a secure, locked area for medications. A resident with diagnoses including pneumonia, heart failure, and hypokalemia, and with intact cognitive ability per the Minimum Data Set assessment, was observed sleeping with a potassium pill in a medication cup on her bedside table. An LPN confirmed that the medication had been placed in front of the resident 45 minutes to an hour prior to observation. There was no documentation of an assessment for self-administration, and the medication was not secured in the resident's room. The Director of Nursing confirmed that the required assessment had not been completed.