Failure to Assess and Document Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess two residents for their ability to self-administer medications, as required by facility policy. For one resident with diagnoses including heart failure, diabetes, depression, and mild cognitive impairment, observations revealed multiple medications, including a bottle of Fluticasone nasal spray and multivitamin gummies, left unsecured on the bedside table. The resident reported self-administering these medications, but there was no documentation of an interdisciplinary team assessment or approval for self-administration, nor was there evidence of secured storage to prevent access by others. Another resident, diagnosed with high blood pressure and high cholesterol, was found to have a bottle of Tylenol and CBD gummies unsecured in a dresser drawer. This resident also reported self-administering Tylenol daily, with no documentation of an assessment for self-administration or secured storage of the medications. Interviews with staff and the administrator confirmed that neither resident had been assessed for self-administration of medications as required by facility policy.