Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident’s ability to self-administer medications in accordance with its Self-Administration of Medication policy, which requires that any resident requesting to self-administer medications be evaluated by the interdisciplinary team (IDT) and that the assessment be documented in the electronic medication record and reviewed with the resident and/or responsible party. The resident, who had multiple diagnoses including multiple myeloma and diabetes, was observed sitting in his room placing eye drops in his eyes, and a bottle of Refresh Tears was seen on his bedside table. Review of the resident’s medical record showed no physician order for Refresh Tears and no IDT self-administration assessment. The DON stated that the resident should not have had the Refresh Tears at his bedside and confirmed that the resident had not been assessed by the IDT for self-administration of medications. This failure created the potential for adverse effects if medications were self-administered inappropriately by the resident.
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