Failure to Complete Self-Administration Assessment and Secure Medication Storage
Penalty
Summary
The facility failed to ensure that a proper assessment for self-administration of medications was completed and that provider orders were obtained for all medications kept at bedside for one resident. The resident, who had intact cognition and diagnoses including femur fracture, severe obesity, and asthma, was observed with multiple medication containers (Tums, Tussin DM, multi-vitamin, and anti-diarrheal medication) on her bedside table. The self-administration evaluation indicated it was acceptable for the resident to self-administer after nurse setup, but the assessment was incomplete, as key sections regarding the resident's ability to manage and store medications were not checked. Additionally, the provider order list did not include orders for several of the medications found at the bedside. Interviews with staff confirmed that the resident was allowed to self-administer medications after nurse setup, but the process was not being followed correctly. The LPN acknowledged that medications should have been kept in the nurse's cart and that provider orders were missing for some medications. The DON stated that an assessment and provider order are required for self-administration and that medications should be stored securely, not on a bedside table. The facility's policy also requires self-administered medications to be stored in a safe and secure place, which was not adhered to in this case.