Failure to Follow Policy for Self-Administration of Medication
Penalty
Summary
The facility failed to follow its policy regarding self-administration of medications for a resident with multiple diagnoses, including congestive heart failure, hypertension, diabetes mellitus, cardiomyopathy, and stage three kidney disease. The resident, who had moderate cognitive impairment, was observed with a vial of prescription Viagra on his bedside table and reported self-administering the medication for the past two to three months. Nursing staff confirmed that the medication was left at the bedside for the resident to take as needed, despite facility policy requiring a physician's order, a care plan, and an assessment of the resident's ability to self-administer medications safely. Record review revealed that the only assessment of the resident's ability to self-administer medication was over a year old and related to an inhaler, not the current medication in question. There was no current physician order or care plan authorizing self-administration of Viagra or allowing the medication to be kept at the bedside. Facility leadership confirmed that the required assessment, physician order, and care plan were not in place, and that the resident's ability to self-administer had not been evaluated as required by policy.