Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined whether a resident was able to self-administer medications, specifically Systane ophthalmic eyedrops, for one of five residents reviewed for resident rights. The resident, an older adult female with an intact cognition score (BIMS 14), had orders for Systane and Artificial Tears ophthalmic solutions to be kept at bedside for self-administration. However, there was no documented assessment completed to determine if she was clinically appropriate to self-administer these medications, and her baseline care plan indicated she was not able to self-administer any medications. Observations revealed that the resident had both Systane and Artificial Tears eye drops at her bedside and reported self-administering them at bedtime without staff supervision or confirmation. Interviews with nursing staff, including an RN, ADON, LVN, and Medication Aide, showed a lack of awareness regarding whether the resident had been assessed for self-administration or had appropriate orders. Staff assumed the resident was permitted to self-administer based on her alertness and the presence of the medications at bedside, but none could confirm that the required assessment or interdisciplinary team determination had occurred. The facility's policy required that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determined the resident had the decision-making capacity to do so safely. Despite this, the resident was allowed to keep and self-administer eye drops at bedside without the necessary assessment or documented team decision, resulting in a failure to follow established procedures for safe medication administration.