Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medications, as required by policy and physician oversight. One resident, who had diagnoses including Alzheimer's disease, dementia, COPD, chronic respiratory failure, schizoaffective disorder, chronic hepatic failure, scoliosis, and pneumonia, was observed with multiple medications and supplements at his bedside. These included an albuterol inhaler, fluticasone inhaler, beet root supplement, and diclofenac cream. The resident reported self-administering these medications as needed or as part of his routine. However, the physician's order sheet did not include an order for the beet root supplement, nor did it document any authorization for the resident to self-administer any medications. Interviews with facility staff confirmed that there was no assessment conducted to determine the resident's ability to safely self-administer medications, and no physician order was obtained to permit self-administration. The resident's care plan also lacked documentation regarding self-administration. Facility policy requires an assessment and physician approval before a resident may self-administer medications, with appropriate documentation in the care plan and medication record. These steps were not followed for this resident, resulting in a deficiency.