Failure to Assess and Document Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents were properly assessed for safe self-administration of medications, as required by facility policy. One resident, who was cognitively intact and able to ambulate independently, was observed with an uncovered tub of zinc oxide cream in his restroom, which he reported applying himself to prevent skin irritation. There was no documentation in the medical record of a physician's order, an interdisciplinary team (IDT) assessment, or a care plan addressing self-administration of this medicated cream. Staff confirmed that medicated creams should not be left unattended and verified the absence of required documentation for self-administration. Another resident, also cognitively intact, was found with Halls cough drops containing menthol on her bedside table, which she reported taking independently without informing staff. Staff initially considered the cough drops as candy, but upon review of the packaging, acknowledged they were medicated and should have required a physician's order, assessment, and care plan for self-administration. The medical record for this resident also lacked evidence of a physician's order, self-administration assessment, IDT notes, or a care plan related to self-administration of medication.