Failure to Assess and Document Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for self-administration of medications as required by facility policy. The policy states that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determines the resident has the decision-making capacity to do so safely. Review of the resident's electronic medical record, care plan, assessments, progress notes, and physician orders revealed there was no documented assessment or care plan addressing the resident's ability to self-administer medications. No orders related to self-administration were found, and there was no evidence of an interdisciplinary team meeting or progress note documenting this capability. Despite the lack of assessment and documentation, the resident was observed self-administering a prescribed nasal spray medication in her room, with the medication being left at her bedside for her use. The resident confirmed during interview that she had been self-administering the nasal spray independently for a long time, and nursing staff acknowledged that the medication was routinely left in the resident's room for her to use on her own. The DON stated that such practices should be documented in the assessments, care plan, and IDT meeting notes, but this was not done for this resident.