Failure to Implement Self-Administration Medication Policy and Control Bedside Medications
Penalty
Summary
The deficiency involves the facility’s failure to implement its self-administration of medication policy for a resident who had medications stored at bedside without appropriate orders or assessment. During observation, two unlabeled insulin pens (Lantus and Lispro) and an unlabeled bottle of Acetaminophen 325 mg were found on the resident’s bedside table. The resident reported that staff were aware of these medications being kept at bedside and stated that she was currently self-administering Acetaminophen/Tylenol, while also reporting that she was no longer able to self-administer insulin since returning from a recent hospitalization due to weakness in her hands. Review of the resident’s medical record showed diagnoses including type 2 diabetes mellitus without complications and active orders for Acetaminophen 325 mg every 6 hours as needed for pain, as well as scheduled Humalog (insulin lispro) before meals and Lantus (insulin glargine) at bedtime. Interviews with nursing staff confirmed that medications should not be left at bedside and that, if a resident is to self-administer medications, there must be a physician order and an assessment in place. The RN and the Assistant DON both stated that self-administration requires an order, an assessment, and care plan documentation. Record review with facility staff revealed there was no completed self-administration of medication assessment for this resident, no orders indicating self-administration for any medications, and the care plan only noted insulin use with an intervention to modify the care plan based on patient progress and needs. The facility’s written Self-Administration & Medication Storage Policy requires assessment of residents who request to self-administer, communication of assessment results to the attending physician, obtaining an order to self-administer, and quarterly or significant-change follow-up observations to determine continued competency, none of which were documented for this resident despite medications being present at bedside and the resident’s report of self-administering Acetaminophen.
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