Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A staff member prepared medication for a resident and placed it in a medication cup on the resident's bedside table while the resident was sleeping, stating that the resident preferred to take her medications when she was ready. The staff member indicated that this was a common practice, as the resident often did not want to take medications in front of staff. The resident confirmed that staff frequently left medications in her room for her to take at her convenience, and that staff did not always observe her taking them. Review of the resident's electronic medical record revealed there was no physician's order authorizing self-administration of medications, nor was there documentation of a safety assessment to determine if the resident was capable of safely self-administering her medications. Facility policy requires a prescriber's order and an interdisciplinary team assessment before permitting residents to self-administer medications, but these steps were not completed for this resident.