Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
Surveyors identified a failure to appropriately assess and determine the clinical appropriateness of self-administration of medications for one resident. During an observation, the resident was found lying in bed with multiple medication bottles on the bedside table, including Tylenol 500 mg tablets, Tylenol PM, and TUMS. A registered nurse stated that medication bottles should not be kept at the bedside and acknowledged that the resident had medications there. Record review for this resident showed that on the admission assessment, the resident had indicated they did not want to self-administer their own medications. The medical record did not contain a physician's order for Tylenol PM, any authorization for self-administration of Tylenol 500 mg or TUMS, or a care plan documenting the resident's capacity for self-administration. The DON confirmed that the facility’s process for self-administration requires a physician’s order, completion of an assessment, locked storage at the bedside, and documentation on the MAR and in the care plan, none of which were present for this resident.
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