Failure to Evaluate and Authorize Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly evaluated and authorized to self-administer medication, as required by facility policy. According to the policy, residents may self-administer medications only after an interdisciplinary team evaluation and approval from their medical provider, followed by a physician's order. During a medication pass observation, a can of nasal spray was found on a resident's over-bed table, and the LPN confirmed there was no physician order for self-administration of this medication. Review of the resident's records showed no current order or interdisciplinary assessment for self-administration. The Director of Nursing confirmed that the necessary evaluation and authorization had not been completed for this resident, who had diagnoses of hypertension, diabetes, and COPD.