Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that an evaluation and assessment for safe self-administration of medications was conducted for a resident who was observed to have medications at their bedside. According to the facility's policy, residents desiring to self-administer medications must be assessed by the interdisciplinary team for their cognitive, communication, visual, and physical abilities, and a physician's order must be obtained if the resident is deemed capable. However, review of the resident's records showed no documentation of such an assessment prior to the resident having access to their prescribed Albuterol Sulfate inhaler and Biotene oral spray at their bedside. Observations confirmed that the resident had both medications within reach and reported using them as needed for asthma and dry mouth. Interviews with facility staff, including an LPN, Resident Care Manager, and DON, confirmed that the required assessment and physician's order were not completed before the resident was allowed to self-administer these medications. Staff acknowledged that the resident should not have had medications at bedside without the proper assessment and authorization.