Failure to Assess and Care Plan for Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including progressive supranuclear ophthalmalgia, type II diabetes, and cognitive communication deficit was admitted with active physician's orders for two types of eye drops. The resident was assessed as cognitively intact but required supervision or touching assistance with personal hygiene. Despite this, there was no assessment in the medical record for the resident's ability to self-administer medications, nor was there a care plan addressing self-administration of medication. Observations revealed that multiple bottles of eye drops, both opened and unopened, were present on the resident's nightstand, and the resident reported self-administering the drops as needed. Nursing staff were aware that the resident had eye drops at the bedside, with one nurse stating the resident's spouse brought them in, but did not report this to management or ensure the medications were secured. The unit manager and DON confirmed that medications should not be kept at the bedside without a care plan for self-administration, and the resident did not have such an order. The physician assistant also confirmed that no order had been written for self-administration and expressed uncertainty about the resident's ability to administer the drops correctly.