Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that residents were initially assessed by the interdisciplinary team (IDT) to determine if they were safe to self-administer medications, as required by facility policy, for one resident. The facility’s Self-Administration of Medications policy, revised February 2021, stated that residents have the right to self-administer medications only if the IDT determines it is clinically appropriate and safe, and that such determinations must be documented in the medical record and care plan. During observation, a surveyor noted that Resident #35 had Calcitonin nasal spray on her overbed table; the resident reported that she kept it in her room for use when she needed it and that she had used it before coming to the facility. Review of the resident’s medical record and care plan showed no documentation of an IDT assessment or authorization for self-administration of medications. The Regional Nurse Consultant confirmed that the resident should not have had the Calcitonin nasal spray in her room and that no IDT assessment for self-administration had been completed.
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