Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to conduct an interdisciplinary team (IDT) assessment and obtain physician orders for self-administration of medications for two residents. One resident had a bottle of isopropyl alcohol, which he used daily to clean his skin, left unattended on his tray table. This resident had purchased the isopropyl alcohol himself, and nursing staff were aware of his use. Review of his records showed no documentation of an IDT assessment for self-administration or a physician order for the isopropyl alcohol. The resident was cognitively intact and had a diagnosis of a non-pressure chronic ulcer of the left foot. Another resident was found with a bottle of hydrogen peroxide and a bottle of folic acid on his bedside table, both left unattended. The resident reported using the hydrogen peroxide to clean his teeth weekly and taking folic acid daily, with both items brought in by his son. Nursing staff were aware of his self-administration, but records indicated that the IDT had documented 'No' for self-medication administration and there were no physician orders for these items. This resident was also cognitively intact and had a diagnosis of anemia. Facility staff confirmed that medications should not be left at bedside unattended and that required assessments and orders were missing.