Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the ability to self-administer medication, specifically lubricant eye drops, as required when the interdisciplinary team determines this practice may be clinically appropriate. The resident, who had a history of Parkinsonism with associated tremors, anxiety disorder, mild dementia, and other conditions, had been self-administering over-the-counter eye drops from admission until the issue was identified by surveyors. There was no documentation of an assessment for self-administration of medication, nor was there a care plan focus addressing this practice for the resident. Observations revealed that the resident kept eye drops at her bedside and self-administered them without staff knowledge or training, despite experiencing tremors that could impact her ability to safely instill the drops. The DON confirmed that the resident had not been assessed for self-administration prior to the survey, and that the facility policy required such an assessment. The facility's medication administration policy did not address self-administration, and no specific policy for self-administration of medication was provided during the survey.