Failure to Assess and Document Resident Self-Administration of Medications
Penalty
Summary
The facility failed to properly assess and document a resident's ability to self-administer medications, as required by its own policy. One resident, who had a history of left leg fracture, respiratory failure, a tracheostomy (without ventilator), and required a PEG tube for nutrition and medication administration, was observed self-administering all of his medications. Although the care plan indicated that the resident preferred and was capable of self-administering medications as determined by the interdisciplinary team, the facility's documentation and oversight were inconsistent. The Medication Administration Record (MAR) did not consistently indicate which doses were self-administered, and the Director of Nursing was unaware that the resident was self-administering all medications, being only aware of nebulizer treatments. Observations and interviews revealed that the resident was seen crushing and administering medications via PEG tube, with the nurse providing visual oversight only most of the time. The nurse confirmed that she documented medication administration in the MAR as with any other medication, regardless of whether it was self-administered. The facility's policy required an assessment of the resident's ability to self-administer medications and clear documentation in the MAR, but these steps were not consistently followed, leading to a deficiency in ensuring safe medication management for the resident.