Failure to Assess and Document Resident's Ability to Self-Administer 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, if a resident wishes to self-administer medications, an interdisciplinary team member must complete a skills assessment form to determine the resident's ability, and this assessment should be documented in the medical record. Additionally, the physician or provider should be notified, and the self-administration status should be reflected in the electronic health record. For bedside storage, medications must be kept out of reach of other residents, in their original containers, and nurses must verify and document their use. In this case, a resident with end-stage renal disease and intact cognitive ability was observed with multiple unsecured medications, including Velphoro and lidocaine products, on the bedside table and dresser. The resident reported using the lidocaine prior to dialysis. There was no documentation that the facility had assessed the resident's ability to self-administer these medications, nor was there evidence that the medications were secured as required. The DON confirmed that the assessment had not been completed in accordance with facility policy.