Failure to Assess Appropriateness for Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was clinically appropriate to self-administer medications, as required by policy. A resident with diagnoses including polyosteoarthritis, type 2 diabetes mellitus, muscle weakness, and unspecified macular degeneration was observed with a cup of medications left on her bedside table for independent administration. There was no completed assessment or physician order in place at the time of the observation to support that the resident was safe to self-administer medications. The facility's policy requires an interdisciplinary assessment of the resident's physical and cognitive abilities, as well as a physician order, before allowing self-administration of medications. Record review showed that the resident had a BIMS score indicating cognitive intactness but required substantial to maximal assistance with activities of daily living and had limited range of motion in both upper extremities. The assessment tool used by the facility indicated that the resident could not name her medications, dosages, or reasons for use, and the assessment and order for self-administration were only completed after the surveyor's observation. Interviews with staff revealed that medications were left at the bedside based on the resident's preference to have them available before breakfast, but staff acknowledged that the resident did not meet all criteria for self-administration and that the required assessment process had not been followed prior to the incident. Further interviews with the resident and staff confirmed that the resident had recently needed help with medications and did not refuse to eat breakfast unless medications were present, contrary to staff assumptions. The staff responsible for completing the assessment had not directly discussed the process or the resident's preferences with her, and there was confusion among staff about the criteria required for self-administration. The deficiency was identified due to the lack of a completed assessment and physician order prior to allowing the resident to self-administer medications.