Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A facility failed to ensure that an assessment for safe self-administration of medication was conducted for a resident when two open containers of topical ointment were found on the resident's overbed table. During observation and interview, the resident stated she applied the ointment to her lower legs when she felt itchy and would use more if she wanted. The containers were labeled as zinc oxide 25%. Review of the resident's admission record showed a history of infectious and parasitic diseases, and a history and physical indicated the resident was mentally capable of making decisions. However, there was no documented evidence that a self-administration assessment had been completed. A registered nurse confirmed that no assessment for self-administration of medications had been conducted for the resident, and stated that it was not safe for the resident to have medications at the bedside without such an assessment. The assistant director of nursing stated that licensed nurses were expected to follow the facility's policy and procedure regarding self-administration assessment and medication administration. Facility policy required an interdisciplinary team assessment and periodic re-evaluation for residents wishing to self-administer medications, and that self-administration was only allowed when specifically authorized by the attending physician. These procedures were not followed in this instance.