Failure to Assess and Document Resident Self-Administration of Medication
Penalty
Summary
The facility failed to determine if it was safe for a resident to self-administer medication, as required by its own policy and regulatory standards. During an observation, a resident was found with a medication cup containing Diclofenac Sodium topical gel 1% at the bedside, which the resident stated was left by nursing staff for later self-application. The nurse present confirmed that licensed staff were not supposed to leave medications at the bedside, indicating a deviation from established procedures. A review of the resident's medical record revealed there was no physician's order, assessment, or care plan authorizing or addressing self-administration of medication. The resident's history and physical examination indicated the capacity to understand and make decisions, but there was no documentation of an interdisciplinary team assessment to determine if self-administration was clinically appropriate or safe. The Director of Nursing confirmed the absence of required documentation and orders for self-administration of medications for this resident.