Failure to Assess Resident's Capability for Self-Administration of Medications
Penalty
Summary
The facility failed to assess and determine a resident's capability to self-administer medications as required by its own policy. The policy mandates that residents who wish to self-administer medications must undergo an assessment by the interdisciplinary team to determine their ability to do so safely, including evaluating their understanding of medication labels, dosages, administration times, and safe storage. In this case, a resident with multiple diagnoses, including aftercare following abdominal surgery, asthma, anxiety, and depression, was observed with a medication cup containing 22 pills and a prepared nebulizer treatment at the bedside. The resident reported that nursing staff sometimes left medications at the bedside and sometimes stayed during administration. Interviews with staff revealed that medications and respiratory treatments were left at the resident's bedside without confirmation of a completed or approved self-administration assessment. The staff member involved considered the resident cognitively intact but could not verify that the required assessment had been performed. Further review by the Director of Nursing confirmed that the clinical record lacked a current physician order for self-administration, a self-administration assessment, and a care plan documenting self-administration. This failure to follow policy and regulatory requirements resulted in a deficiency related to pharmacy services, resident care policies, and nursing services.