Failure to Assess Resident for Self-Administration of Medications by IDT
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) was involved in assessing and determining the appropriateness of self-administration of medications for a resident. The resident, who had diagnoses including type 2 diabetes, lumbar spine disc degeneration, hypertension, and a history of lung cancer, was admitted with intact cognition and some need for assistance with activities of daily living. Despite these conditions, the resident was observed organizing and self-administering medications at bedside without an IDT assessment or documented approval for self-administration. The resident reported having self-administered medications since admission and had not participated in an IDT meeting regarding this practice. Facility staff, including an LVN and the DON, confirmed that the resident had been self-administering medications without the required IDT assessment or physician order. The facility's policy requires that the IDT assess each resident's ability to self-administer medications and determine the safety and appropriateness of this practice, with documentation in the care plan. This assessment had not been completed for the resident, and the required procedures for storage, documentation, and ongoing quarterly reassessment were not followed.