Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was clinically assessed and determined appropriate to self-administer medications before doing so, as required by facility policy. The facility’s Self-Administration of Medications policy states that residents may self-administer medications only if the interdisciplinary team determines the practice is safe for the resident and others, and if there is a prescriber’s order, following an assessment of the resident’s cognitive, physical, and visual abilities during the care planning process. The resident in question was admitted with multiple diagnoses, including alcohol use, chronic pain, generalized anxiety disorder, insomnia, cerebral aneurysm (non-ruptured), cocaine abuse, homelessness, major depressive disorder, persistent mood disorder, post-traumatic stress disorder, and restlessness and agitation. The most recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact and their own decision-maker. Surveyors learned from nursing staff that the resident had medications stored in her bedroom and in a backpack, and LPNs reported that the resident would not allow staff to look through the backpack, so they did not know what medications were present. Review of the resident’s care plan and orders showed that the resident had not been assessed or care planned for safe self-administration of medications. The DON later documented that, upon going through the resident’s bag with the resident, multiple medications and supplements were found, including Topiramate 100 mg, Tylenol 500 mg, Ibuprofen 200 mg, Vitamin C 500 mg, Jet Alert, Vitamin D3 2000 IU, an iron supplement 28 mg, Docusate Sodium 100 mg, Ashwagandha pills, and Fluoxetine 20 mg. At the time of the survey, the DON acknowledged that there was no completed self-administration assessment for this resident, and that he had only recently become aware that the resident had medications in her room. The facility therefore did not ensure the resident was clinically appropriate to self-administer medications in accordance with its policy.
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