Failure to Assess and Approve Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were clinically assessed and approved for self-administration of medications, as required by policy. In one instance, a resident with diagnoses including generalized anxiety disorder, polyosteoarthritis, and congestive heart failure was observed with a cup of medications left on his bedside table for independent consumption. There was no physician's order, care plan, or assessment indicating that this resident was safe to self-administer medications. Both the LPN and DON confirmed that no assessment or order was in place, despite the resident regularly taking medications independently. Another resident was found with multiple medication containers at bedside and scheduled medications left out for more than one hour, contrary to her self-administration assessment, which only permitted Lactaid at bedside and required nurse follow-up within one hour. Observations revealed that medications, including pills from the previous evening, remained at the bedside and on the floor, and the nurse did not follow up as required. The DON confirmed that only Lactaid should be at bedside and that the nurse failed to ensure timely medication administration and removal of unauthorized medications. A third resident was observed with a Combivent inhaler at bedside on multiple occasions, but there was no assessment completed to determine if self-administration was clinically appropriate. Both the LPN and DON confirmed that this resident had not been assessed for self-administration, and facility policy dictates that medications should not be left at bedside without such an assessment. These findings demonstrate a pattern of noncompliance with the facility's own policy regarding the clinical assessment and approval process for resident self-administration of medications.