Failure to Assess and Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure ongoing assessment and care planning for residents who desired to self-administer medications. In one case, a cognitively intact resident had multiple medications, including eye drops, an inhaler, and a topical cream, stored at his bedside. While there were physician orders for self-administration of some medications, there were no orders for others, and the required self-administration assessments were either outdated or missing. The resident reported not being taught how to take the medications, and there was no documentation of a care plan addressing self-administration. The facility's policy required regular assessment and demonstration of self-administration ability, but these procedures were not followed, and the policy did not specify how bedside medications should be secured. Another resident with mildly impaired cognition also kept an inhaler and nasal sprays at his bedside. Although there was a physician order for unsupervised self-administration of the inhaler, there were no such orders for the nasal sprays. The resident stated he was not assessed by nursing staff for his ability to self-administer these medications, and there was no documentation of such assessments or related care planning in his record. These findings indicate a lack of compliance with facility policy and federal regulations regarding the assessment, authorization, and care planning for self-administration of medications.