Failure to Assess and Authorize Resident Self-Administration of Topical Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure the interdisciplinary team determined that a resident could safely self-administer a topical medication before allowing self-administration. Surveyors observed that Resident #2 had an antifungal cream on their bedside table, and the facility’s policy stated that residents may only self-administer medications after an interdisciplinary team assessment is completed and documented on a Medication Self-Administration Assessment Form in the medical record. Resident #2 had a physician’s order for antifungal external cream 2% to be applied to the groin every shift for redness and had a quarterly assessment showing a BIMS score of 13, indicating intact cognition, with diagnoses including hemiplegia or hemiparesis and chronic kidney disease stage 3. However, there was no self-administration of medication assessment or physician order to self-medicate in the electronic medical record. An LPN reported not knowing who gave the resident the antifungal cream and acknowledged that while cognitively intact residents could have an order to apply creams themselves, this resident did not have such an order, and the administrator confirmed they were unable to locate a medication self-administration assessment for this resident. This sequence of observations, record reviews, and staff interviews showed that the facility did not follow its own policy requiring an interdisciplinary assessment and physician order before allowing a resident to self-administer medication, resulting in the identified deficiency for one of six sampled residents reviewed for medication administration.
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