Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The deficiency involves the facility’s failure to determine whether it was safe for a resident to self-administer medications before leaving medications at the bedside. Facility policy dated 12/11/25 stated that residents may only self-administer medications after the interdisciplinary team determines which medications can be self-administered safely. The clinical record showed that the resident was admitted on an unspecified date and had diagnoses including hypertension, anemia, and dementia, with a BIMS score of 10 indicating moderate cognitive impairment. Despite this, there was no documented self-administration assessment, no physician order authorizing self-administration, and no care plan addressing self-administration of medications. During an observation, the resident was found lying in bed with a clear medication cup containing four pills (one white, one brown, one peach, and one black) on the bedside table, with no nurse present in the room. An RN acknowledged that it was an oversight and confirmed the presence of the medication cup at the bedside. Review of the resident’s physician orders and care plan did not show any authorization or planning for self-administration of medications, and review of the clinical record did not reveal a completed self-administration assessment. The DON confirmed that the facility failed to determine whether it was safe for this resident to self-administer medications.
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