Medication Left at Bedside Without Required Self-Administration Assessment
Penalty
Summary
Surveyors observed that a resident had a medication cup on the bedside table containing a small white round pill imprinted "111," and the resident stated she was unsure what the pill was. Review of the medication cart at that time identified the pill as exemestane 25 mg, a steroidal drug that had been ordered once daily since 10/9/23 for this resident, who had diagnoses including malignant neoplasm of the upper-inner quadrant of the left female breast. The most recent Quarterly MDS assessment indicated the resident was cognitively intact and independent for eating. During interview, the DON confirmed that the resident did not have a completed self-administration of medications assessment, despite facility policy requiring the nurse to evaluate and approve each resident who self-administers medications by completing a Self-Administration of Medication Assessment form before allowing self-administration. This failure to complete the required assessment occurred in the context of a medication being left at the bedside for the resident without documented evaluation of her ability to safely self-administer, as required by the facility’s Self Administration of Medications policy and 410 IAC 16.2-3.1-11(a).
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