Failure to Assess and Authorize Self-Administration Before Leaving Medications at Bedside
Penalty
Summary
Facility staff failed to follow their medication administration policy requiring an assessment and physician authorization before allowing residents to self-administer medications. The policy stated that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determined they had the decision-making capacity to do so safely. One resident was admitted with diagnoses including metabolic encephalopathy and hypertension, and the admission MDS showed a BIMS score of 5/15, indicating severe cognitive impairment. Despite this, whole medications were left at the bedside over a weekend without any documented assessment of the resident’s ability to self-administer medications. An incident note documented that the resident’s daughter found two pills in the resident’s room on the bedside table, which a nurse indicated might have been blood pressure medication. Review of the resident’s care plan showed there was no care plan addressing self-administration of medications, and review of assessments confirmed the resident had not been evaluated for self-administration. Additionally, physician orders did not include any order to leave medications at the bedside for the resident to self-administer. In an interview, the Administrator acknowledged that the resident would not be able to self-administer medications and noted the resident had previously lived in a memory care unit before admission to the skilled nursing unit.
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