Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for self-administration of medications as required by its policy. According to the facility's Self-Administration Medications policy, an assessment must be completed for each patient requesting to self-administer medications and repeated quarterly, with documentation kept in the medical record. For one resident with multiple diagnoses including polyosteoarthritis, morbid obesity, diabetes, COPD, and functional quadriplegia, observations revealed a Ventolin inhaler at the bedside, and the resident confirmed self-administration of the inhaler. Record review showed there was no facility assessment for this resident to self-administer medications, and the DON confirmed the absence of such an assessment. Another resident with diagnoses including aggressive periodontitis, anemia, type 2 diabetes with chronic kidney disease, and hemiplegia was observed with a prescription oral rinse at the bedside. The resident stated she used the mouthwash independently, and an LPN confirmed the oral rinse should not have been at the bedside. The DON also confirmed that this resident had not been assessed for self-administration of medication. In both cases, the facility did not follow its own policy to assess and document the appropriateness of self-administration for these residents.