Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
Facility staff failed to assess a resident's ability to safely self-administer medications prior to allowing the resident to keep and use medications at the bedside. Observations revealed that the resident had an inhaler, CBD pain ointment, menthol pain ointment, and vitamin D3 stored in a basket at the bedside. The resident reported using the pain ointments for relief during chemotherapy and self-administering the inhaler twice daily, with the nurse leaving the inhaler in the room for the resident to use. Interviews with staff indicated that there was a process for approving self-administration, but in this case, no assessment had been completed before the medications were left at the bedside. Further review of the clinical record confirmed the absence of a self-administration assessment and that the resident's care plan did not address self-administration of medications. The Minimum Data Set did not indicate that the resident was independent with medications. Facility policy required an assessment to ensure residents could safely self-administer and store medications in a locked compartment, but these steps were not followed prior to the medications being left at the bedside.