Failure to Develop Care Plan for Medication Self-Administration
Penalty
Summary
The facility failed to develop a person-centered care plan addressing medication self-administration for a resident who was reviewed for medication administration. The facility's policy required that determinations regarding self-administration of medications be documented in the resident's care plan. The resident, who was alert and oriented and had been evaluated and deemed appropriate to self-administer Parkinson's medications, was observed with a pill organizer containing his medications. However, review of the resident's care plan showed no documentation of a focus or interventions related to self-administration of medications. Staff confirmed that a care plan for medication self-administration had not been in place at the time of the assessment and only a new care plan was recently initiated after the deficiency was identified.