Failure to Assess and Authorize Resident Self-Administration of Medications at Bedside
Penalty
Summary
Surveyors identified that the facility failed to assess residents for self-administration of medications and failed to obtain physician orders for medications kept at the bedside. One resident had Systane lubricant eye drops and ointment on the bedside table and reported that no one at the facility had educated her on how to take the medications, stating she already knew how to use them and that they were always kept in her room. Her record showed a diagnosis of exudative age-related macular degeneration with active choroidal neovascularization and an MDS indicating she was cognitively intact. The POS contained an order for Systane ophthalmic gel to be instilled in both eyes every 24 hours as needed for dry eyes, but there was no order for the medication to be kept at the bedside. Her medical record contained no self-administration of medication assessment and no care plan addressing self-administration. Another resident had multiple tubes of topical analgesic and a topical antibiotic on the bedside table and stated she applied the analgesic to her knees for arthritis pain and the antibiotic to the sides of her nose where her eyeglasses rest, adding that the medications were always kept in her room and that no one had educated her on how much she could apply in a day. Her diagnoses included multiple sclerosis, unsteadiness on feet, and primary generalized osteoarthritis, and her MDS showed moderate cognitive impairment. The POS contained no orders for the topical analgesic or topical antibiotic, and her record lacked a self-administration of medication assessment and a care plan for self-administration. The DON stated that she did not currently have residents who self-administer medications, that nurses should assess residents and require them to demonstrate safe self-administration according to physician orders, and that there should be physician orders for medications to be kept at the bedside. The facility’s self-administration policy required IDT assessment of cognitive and physical abilities, documentation and care planning when self-administration is deemed safe, secure storage of self-administered medications, and turning over any unauthorized bedside medications to the nurse in charge.
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