Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the interdisciplinary team assessed and determined the safety of self-administration of medication for a resident. The resident, who was cognitively intact but required partial to moderate assistance with most activities of daily living due to conditions such as metabolic encephalopathy, hypertension, lung cancer, lupus, COPD, weakness, and debility, was observed with an unsecured rescue inhaler at her bedside. There was no documented assessment for self-administration of medication in the resident's electronic health record, nor was there a physician's order permitting self-administration. The resident reported keeping the inhaler with her and self-administering it as needed, despite the lack of formal authorization or assessment. Interviews with nursing staff, including the RN Charge Nurse, ADON, and DON, confirmed that the facility's policy required an assessment and physician order before a resident could self-administer medication, and that medications should be stored securely. Staff were unaware of any residents currently authorized to self-administer medications, and the resident's medication administration record did not reflect any requests for the PRN inhaler. The facility's policy also specified that self-administered medications must be kept in a secure location, which was not the case for this resident.