Deficiencies in Medication Administration and Self-Administration Assessments
Penalty
Summary
Surveyors identified deficiencies in the facility's pharmaceutical services related to medication administration and self-administration assessments. For one resident with congestive heart failure, renal insufficiency, diabetes, and malnutrition, unlabeled and undated lubricating eye drops were found at the bedside, along with other medications not provided by the facility pharmacy. There were no physician orders or self-administration assessments for these medications, and staff were unaware of their origin or whether the resident was permitted to self-administer them. Another resident with acute panmyelosis with myelofibrosis, osteopathic conditions, and dry eyes was observed self-administering Refresh Tears eye drops, which were labeled with the resident's name and kept at the bedside. The resident's medical record included a physician order for unsupervised self-administration of the eye drops, but there was no documented self-administration assessment to support this practice at the time of the survey. Additionally, a bottle of multivitamins was found at the bedside without proper assessment. During medication administration for a third resident, an LPN dropped a pill on the medication cart, picked it up with a bare hand, and administered it to the resident, contrary to the facility's policy prohibiting staff from touching medications with their hands. The LPN acknowledged the error, and the DON confirmed that the pill should have been disposed of and not administered. These findings demonstrate failures in following established policies for medication safety and proper assessment for self-administration.