Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was properly assessed by the interdisciplinary team to determine if it was clinically appropriate for the resident to self-administer medication. The facility's policy requires that residents may only self-administer medications after an interdisciplinary team assessment and documentation of the resident's preference. However, a surveyor observed a medication cup labeled with the resident's name and containing two white tablets (Tylenol) left on the overbed table. The resident, who has diagnoses including hypertension, lumbar radiculopathy, osteoarthritis, benign prostatic hyperplasia, obstructive and reflux uropathy, and anxiety disorder, was found to be cognitively intact with a BIMS score of 15. The resident stated that he sometimes takes the medication himself, indicating that self-administration was occurring without the required assessment. Further review of the resident's medical record and medication administration record revealed no documentation of a self-administration assessment. Staff, including an LPN and the DON, were unable to locate such an assessment, and the LPN later acknowledged that the resident was not authorized to self-administer medication. The facility's own policy and assessment forms indicated that the resident had not expressed a desire to self-administer medications, yet the medication was left at the bedside for self-administration without proper authorization or assessment.