Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was initially assessed by the interdisciplinary team to determine if it was safe for the resident to self-administer medications before doing so, as required by the facility’s Self-Administration of Medications policy dated 11/28/17. That policy specified that the interdisciplinary team must determine safety for self-administration, decide who is responsible for storage and documentation of drug administration and the location of administration, and document these determinations in the medical record and care plan. Surveyors found that these required assessments and documentation steps were not completed. The resident involved had been admitted with multiple diagnoses, including metabolic encephalopathy and acute respiratory failure with hypoxia. During observation, the resident was noted to have OTC Refresh eye drops on the overbed table and stated that the drops were kept in the room for use when needed. Review of the medical record and care plan showed no assessment for self-administration of medications and no documentation authorizing self-administration. In an interview, the RN Clinical Resource Nurse confirmed that the resident should not have Refresh eye drops in the room and had not been assessed for self-administration of that medication.
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