Failure to Assess and Authorize Resident Self-Administration of Antacid Medication
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for the ability to self-administer medications and to ensure appropriate physician orders were in place. The resident was admitted on an unspecified date and had a quarterly MDS assessment indicating she was cognitively intact. Review of the resident’s physician orders showed no order for calcium carbonate (Tums), and review of the medical record revealed no self-administration assessment. Despite this, surveyors observed a bottle of Tums tablets, approximately one-quarter full, on the resident’s bed and later on her over-bed table when the resident was not present in the room. During an interview, the resident stated that her family had brought the Tums because she needed them when she had heartburn, that she did not take them often, but wanted to be able to take them when needed, and she could not recall when she last took them. A nurse later stated she was unaware the resident kept Tums in her room, confirmed there was no order for the resident to self-administer medications, and expressed that the resident would not be safe to self-administer due to periods of lethargy related to her medications. The DON also confirmed there was no order for the resident to self-administer and no existing order for an antacid for heartburn, demonstrating that the resident had unsupervised access to a medication without assessment or physician authorization.
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