Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
A resident with a diagnosis of gastro-esophageal reflux disease (GERD) was observed to have a medication cup containing a pink tablet, identified as a chewable calcium carbonate tablet (TUMS), left unattended on their bedside table. The resident was not present in the room during the observations, nor was any staff member. The medication was ordered to be administered three times daily, but there was no documentation or assessment indicating that the resident had been evaluated for the ability to safely self-administer medications. The Director of Nursing confirmed that no self-administration assessment had been conducted for this resident and acknowledged that medications should not have been left at the bedside. Facility policy requires an interdisciplinary assessment and physician order before allowing residents to self-administer and store medications in their rooms, but this process was not followed in this instance.