Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
A resident who was alert, oriented, and had intact functional cognition was admitted to the facility and was found to have a 32 fl. oz bottle of 3% hydrogen peroxide and a 0.5 fl. oz bottle of lubricating eye drops in their room. The resident reported using hydrogen peroxide to gargle and rinse their mouth when sore, as was their practice at home, and kept lubricating eye drops on hand for eye irritation, though had not used them since admission. Observations on multiple occasions confirmed the presence of these over-the-counter medicated liquids in the resident's room. Review of the resident's medical record revealed that no assessment had been conducted to determine if self-administration of medication was clinically appropriate. Interviews with nursing staff, the DON, and the Administrator confirmed that residents were not permitted to keep medications or medicated liquids at bedside and that the items should have been removed by staff. Despite this policy, the resident's possession of these items went unnoticed by staff during medication administration and routine care, and no assessment for self-administration was documented.