Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents' ability to self-administer medications and did not follow its own policy regarding medication administration. For one resident with diagnoses including end stage renal disease, diabetes, and hypertension, a medication cup containing eight medications was left unattended on the overbed table. The resident, who was cognitively intact per a recent BIMS assessment, stated she had fallen asleep and forgot to take the medications, and then proceeded to take them after being prompted. The LPN confirmed she had left the medications and had not observed the resident taking them, and also acknowledged that the resident had not been assessed for self-administration, which was not in line with facility policy. Another cognitively intact resident with a history of congestive heart failure was observed to have a medicine cup with 13 pills left on the bedside table by an LPN, who stated that the resident preferred to take medications with breakfast and that she would return to check if the medications were taken. The resident also had a bottle of Tums at the bedside, which he reported purchasing himself and using as needed, and stated that the physician had seen the bottle but had not commented. The LPN and RN both confirmed that there was no assessment for self-administration for this resident, and that facility policy did not allow medications to be left at the bedside. Facility policy required that residents may self-administer medications only after an assessment by the Interdisciplinary Care Team, but neither resident had such an assessment or order in place. Staff interviews confirmed that medications were not to be left unattended and that there were no residents currently assessed to self-administer medications. The facility also reported that some residents order their own over-the-counter medications, which staff monitor and remove as needed. These actions and inactions resulted in a failure to assess and authorize self-administration of medications, contrary to facility policy and regulatory requirements.