Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly evaluated and assessed for the safe self-administration of medications, as required by facility policy. Specifically, two residents were observed to have respiratory inhalers at their bedside or on their person, and both reported self-administering these medications. Review of the medical records and staff interviews confirmed that neither resident had undergone a documented assessment for their cognitive and physical ability to safely self-administer medications, nor was there documentation in the medical record or care plan updates reflecting such an assessment. Facility policy requires that residents be assessed for cognition and physical ability before being permitted to self-administer medications, with documentation and care plan updates to follow if deemed appropriate. Observations showed that one resident, with a history of depression, muscle weakness, and cognitive communication deficit but assessed as cognitively intact, kept an inhaler at the bedside and self-administered it. Another resident, alert and oriented, kept an inhaler in their shirt pocket and also self-administered it. Staff interviews confirmed that the expectation was for assessments and secure storage, but these steps were not completed for the residents involved.