Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A deficiency was identified when a resident was observed with two capsules of Tamsulosin/Flomax in a medication cup at their bedside. The resident, who had an intact cognition per the most recent MDS, stated that the medication was brought by a nurse but was unsure when. Upon inquiry, an LPN confirmed the medication was scheduled for nighttime administration and suggested it may have been left by the night nurse. Review of the resident's electronic health record revealed no assessment or care plan for self-administration of medication, and there was no physician order permitting the resident to keep medication at the bedside. The facility's policy requires an interdisciplinary team assessment and a prescriber's order before allowing residents to self-administer medications. The DON confirmed that nurses are not supposed to leave medications at the bedside and that self-administration should be formally assessed, care planned, and ordered by a physician. The resident's records showed an active order for Tamsulosin to be given at bedtime, but no documentation supported self-administration or leaving medication at the bedside, resulting in noncompliance with facility policy and regulatory requirements.