Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The deficiency involves the facility’s failure to have the interdisciplinary team (IDT) timely determine and document that self-administration of medications was clinically appropriate for two cognitively intact residents who were self-administering medications. For one resident with a diagnosis including personality disorder, record review showed multiple current physician orders for daily and scheduled medications such as aspirin, docusate sodium, acetaminophen, vitamin B-12, gabapentin, Prempro, hydroxyzine, and lisinopril. During observation, this resident was in bed with a bedside table holding a cup containing multiple morning medications, with no staff present. The resident stated she was able to take her own medications and would take them later due to heartburn. An LPN then entered to administer lisinopril, placed a second medication cup with the pill on the bedside table next to the first cup, and left the room, leaving the resident in possession of both cups. The clinical record for this resident lacked a current self-administration assessment and a physician’s order authorizing self-administration. For the second resident, who had a diagnosis including schizophrenia and was assessed as cognitively intact on admission, physician orders included Tums every six hours as needed and Buspar three times a day. Observation found this resident sitting on her bed with a bedside table holding a medication cup containing one greenish pill and one pinkish pill, which the resident identified as Tums. The clinical record for this resident also lacked a documented self-administration assessment and a physician’s order to self-administer medications. In an interview, the Nurse Consultant confirmed she was unable to locate current self-administration assessments for either resident. The facility’s self-medication assessment policy required that self-administration be ordered by the attending physician and approved by the IDT, with assessments offered during routine IDT assessments and care plans updated at least quarterly or with changes, but these steps were not documented for the two residents involved.
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