Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
A deficiency occurred when a resident, admitted with diagnoses including coronary artery disease and diabetes and assessed as cognitively intact, was found to have a bottle of over-the-counter lubricating eye drops in her room for self-administration. The resident reported bringing the eye drops from home and using them as needed for dry eyes. Observations confirmed the eye drops were accessible to the resident on multiple occasions. Record review and staff interviews revealed that the resident had not been assessed for her ability to self-administer medication, as required by facility policy. Nursing staff and the DON confirmed that residents must be evaluated for safety before being permitted to self-administer medications, and that a physician order and secure storage are necessary. The lack of assessment and appropriate storage for the eye drops constituted the deficiency.