Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for safe self-administration of medication as required by its own policies. The policies state that residents may self-administer medications only if the interdisciplinary team (IDT) determines it is clinically appropriate and safe, and this decision must be documented in the medical record and care plan. For the resident in question, who was admitted with diagnoses including orthostatic hypotension and syncope, there was no documentation of an order for self-administration, nor was there any mention in the care plan allowing the resident to keep medications at the bedside. Despite this, two nasal sprays with faded labels were observed in the resident's possession, and the resident reported using them independently for sinus issues. Record review showed the resident was cognitively intact, with a BIMS score of 15, but there was no evidence that the required assessment for self-administration had been completed prior to the resident keeping and using the medications. The facility's DON confirmed that the responsibility for determining self-administration eligibility lies with the RN and Medical Director, and acknowledged that the medications were reordered after it was discovered the labels were unreadable. The lack of assessment and documentation, as well as the presence of medications at the bedside without proper authorization, constituted a failure to follow facility policy and ensure safe medication practices.