Failure to Assess and Document Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess and determine the ability of four residents to self-administer medications, as required by facility policy. Observations revealed that residents were left unattended with medications at their bedside, including pill cups and topical medications, without documented care plans or physician orders authorizing self-administration. For example, one resident with diagnoses of high blood pressure, diabetes, and constipation was found with a pill cup containing medication, and staff confirmed there was no care plan for self-administration. Another resident with dementia and dependence on renal dialysis was also left with a pill cup containing multiple pills, again without a care plan in place. Additional findings included topical medications such as Voltaren gel and Aspercream found in a resident's room without corresponding physician orders or assessments for self-administration. In another instance, a bottle of Flonase nasal spray was left on a resident's bedside stand after being given by a nurse, with the intention for the resident to use it later, but without proper assessment or documentation. Interviews with nursing staff and the Director of Nursing confirmed that the required assessments and care plans for self-administration of medications were not completed for these residents.