Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including transient ischemic attack, seizures, kidney failure, diabetes, and xerosis cutis, was found to have a prescribed medicated lotion (Ammonium Lactate 12%) stored in her room. The lotion was observed on the resident's dresser and later in an unlocked drawer, accessible to the resident. The resident acknowledged that the lotion was hers and that it was used for application to her legs as ordered by her physician. Despite the medication being kept in the resident's room and accessible to her, there was no documentation in the clinical record indicating that the facility had assessed the resident's ability to self-administer medication. Additionally, there were no physician orders or completed assessments authorizing self-administration. This lack of assessment and documentation was confirmed by the Assistant Director of Nursing during an interview.