Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
Facility staff allowed two residents to self-administer medications without conducting a prior assessment or obtaining a physician's order, as required by facility policy. Both residents were assessed as cognitively intact and had multiple medical diagnoses, including diabetes, asthma, atrial fibrillation, spinal stenosis, and hypertension. On the evening in question, an LPN prepared and left oral medications at the bedside for these residents to take upon returning to their rooms, without witnessing the administration or ensuring the medications were secured. The LPN stated this was done to expedite the medication pass, and later confirmed that one resident self-administered the medication while the other was observed taking it after the LPN returned to the room. Clinical record review revealed that neither resident had a physician's order or an interdisciplinary assessment authorizing self-administration of medications. Interviews with the DON and staff development coordinator confirmed that the facility's policy requires both an assessment and a physician's order before residents are permitted to self-administer medications, and that medications should not be left unattended at the bedside. The DON also stated that residents approved for self-administration are provided with a lock box for medication storage, which was not the case for these residents. Additionally, one resident was found with a Trelegy Ellipta inhaler at the bedside, which had been used, without a physician's order or assessment for self-administration. The resident reported self-administering the inhaler daily, and staff were unaware that the device was in the room. Facility policy requires a licensed nurse to assess the resident's ability to self-administer, with interdisciplinary team review and documentation in the medical record, none of which was completed for this resident.