Failure to Assess and Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure safe and appropriate self-administration of medication for one resident. The resident had multiple diagnoses, including dysphagia, seizure disorder, major depressive disorder, dementia, and anxiety, and was documented as having some confusion and requiring assistance with activities of daily living. The resident's care plan indicated that staff would administer medications, and there was no documentation in the care plan or electronic medical record of an assessment for self-administration of medication. Despite this, a plastic medication cup containing unidentified pills was observed on the resident's bedside table within arm's reach while the resident was lying in bed. Interviews with nursing staff and administration confirmed that there was no assessment completed for the resident to self-administer medications, and facility policy required an interdisciplinary team assessment before allowing self-administration. Staff also stated that medications should not be left unattended at the bedside. The lack of assessment and the unattended medication at the bedside constituted a failure to follow facility policy and ensure resident safety regarding medication administration.