Failure to Complete Required Self-Administration Assessment for Bedside Medications
Penalty
Summary
Surveyors found that the facility failed to complete a required self-administration of medication assessment for a resident who had medications left at the bedside. During an initial tour, the resident was observed with a bottle of nasal spray and a bottle of Refresh eye drops on the over-bed table. Record review showed the resident had a diagnosis that included acute respiratory failure and an admission MDS indicating no cognitive impairment, but the clinical record did not contain a self-administration of medication assessment. On a subsequent observation, the same medications remained at the bedside, and in an interview the Director of Nursing confirmed that the resident did not have the required self-administration assessment despite facility policy requiring an IDT assessment and completion of a Self-Administration of Medication Assessment when a resident participates in self-administration. The facility’s written policy titled “Self Administration of Medications,” with a revision date of 1/2015 and identified by the DON as currently in use, states that if a resident desires to participate in self-administration, the Interdisciplinary Team will assess the resident’s competence by completing the Self-Administration of Medication Assessment observation. Despite this policy, the resident’s record lacked such an assessment while medications were accessible at the bedside, leading to the cited deficiency under 3.1-11(a).
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