Failure to Assess and Approve Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and approved for self-administration of medications before being left alone with physician-ordered drugs. The resident, who had diagnoses including type two diabetes mellitus, hypertension, and a history of transient ischemic attack, was cognitively intact as indicated by a perfect BIMS score. During a medication pass, an LPN brought the resident's morning medications into the room, placed them on the overbed table, and then left the room, leaving the medications unattended with the resident. The LPN later returned and administered the medications to the resident. Upon inquiry, the LPN was unsure if the resident had been approved for self-administration of medications and confirmed that she could not observe the medications while out of the room. The Director of Nursing confirmed that the resident had not been approved for self-administration. Facility policy requires that only residents approved by the interdisciplinary team may self-administer medications and that staff must observe residents consuming their medications. The failure to follow these procedures resulted in the resident being left unsupervised with medications without proper assessment or approval.