Failure to Prevent Unauthorized Self-Administration of Medications
Penalty
Summary
A resident with a diagnosis of dementia and a moderate cognitive impairment, as indicated by a BIMS score of 11, was observed with a cup containing seven medication pills on the over bed table in their room. The resident's self-administration of medication assessment documented that they were not approved to self-administer medications. Despite this, an LPN left the medications with the resident at the resident's request, and documented the medications as administered on the MAR. There was no licensed nurse or medication tech present in the room at the time the medications were left with the resident. Facility policy requires that residents may only self-administer medications if the interdisciplinary team determines it is clinically appropriate, and this determination must be documented in the resident's record. The resident's assessment indicated they were not approved for self-administration, yet staff allowed the resident to have unsupervised access to their medications. The incident was confirmed through observation, staff interviews, and record review, with no explanation provided by the facility for the failure to follow policy and assessment findings.