Failure to Ensure Clinical Appropriateness of Self-Administered Medications
Summary
The facility failed to ensure that a resident's right to self-administer medications was clinically appropriate. Resident #78, who had intact cognition and a history of asthma, was found to have an albuterol inhaler at his bedside, which he used without informing the nursing staff. The resident confirmed that he self-administered the inhaler as needed for shortness of breath but did not communicate this to the nurses. The medical record review revealed no documentation of albuterol administration, and there was no assessment titled Medication Self-Administration Safety Assessment for the resident. The facility's policy required an interdisciplinary team to determine the clinical appropriateness of self-administration and to secure the medication properly in the resident's room, which was not followed in this case. Interviews with the resident, an LPN, and the Director of Nursing (DON) confirmed that the resident self-administered the medication without proper assessment or documentation. The DON acknowledged that any resident wishing to self-administer medications should be assessed for safety and appropriateness, and this assessment should be documented in the resident's medical record. However, a facility-generated report indicated that no residents were currently approved to self-administer medications, highlighting a discrepancy between policy and practice. The facility's failure to conduct the necessary assessments and ensure proper documentation led to this deficiency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with COPD and diabetes was allowed to keep an albuterol HFA inhaler at the bedside and self-administer it as needed, sometimes using it twice daily, without documented assessment for safe self-administration as required by facility policy. The only self-administration evaluation on file addressed nebulizer treatments after nurse set-up, and there was no physician order for nebulizer use. Observations showed the inhaler on the over-bed table and the resident taking two puffs, while the CNO later confirmed that no assessment for inhaler self-administration could be found in the record.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
The facility failed to follow its self-administration of medications policy by not obtaining an IDT assessment or documenting approval before allowing a resident to keep and use Calcitonin nasal spray in their room. The policy required that residents may self-administer medications only if the IDT determines it is clinically appropriate and safe, with this decision documented in the medical record and care plan. However, a resident was observed with Calcitonin nasal spray on the overbed table and reported self-administering it as needed, while record review showed no IDT assessment or care plan authorization. A Regional Nurse Consultant confirmed the resident should not have had the medication in the room and had not been assessed for self-administration.
A resident with breast cancer, prescribed daily exemestane 25 mg, was found with a medication cup at the bedside containing a small white pill she could not identify. Review of the medication cart confirmed the pill was exemestane. Although the resident was documented as cognitively intact and independent for eating, the DON acknowledged there was no completed self-administration of medications assessment for this resident, despite facility policy requiring a nurse-conducted Self-Administration of Medication Assessment and approval before any resident self-administers medications.
A resident with end stage renal disease and other serious conditions was found with an opened bottle of naproxen and multiple opened tubes of prescription lidocaine-prilocaine cream at the bedside, which the resident reported self-administering for headaches and prior to dialysis. The resident had no assessment for self-administration, no related physician orders, and no care plan addressing self-administration, and the assigned medication aide, unit manager, and DON were unaware that the resident possessed or was using these medications. The physician stated that these medications should not be self-administered without supervision and that residents must be assessed for safe self-administration, but this process had not been completed for the resident, and the medications were stored unsecured in the room.
A resident with hemiplegia and intact cognition had no documented self-administration of medication assessment in the EMR and no care plan addressing self-medication, yet medications were left at the bedside in a pill cup by a CMA. The resident questioned what the pills were, and an LN, upon entering the room, could only tentatively identify one pill and had to remove the cup to verify with the CMA. The resident reported never being assessed to self-administer medications, while administrative staff later stated that appropriate self-administration should be care planned with a provider order and that medications should not be left at the bedside, contrary to the observed practice and the facility’s own medication administration policy.
Failure to Assess Resident for Safe Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident was properly assessed for safety to self-administer medication before allowing bedside use of an inhaler. Facility policy on Self-Administration of Medications, revised 9/16/25, stated residents may self-administer medications when it was determined to be safe and appropriate. The resident, admitted with multiple diagnoses including COPD and diabetes, had a physician’s order dated 4/9/26 for Albuterol Sulfate HFA inhaler, one puff every four hours as needed for shortness of breath, with permission to keep the inhaler at the bedside. A Self-Administration of Medication Evaluation dated 3/24/26 documented the resident was fully capable of administering nebulizer treatments after set-up by the nurse, but there was no corresponding physician’s order for nebulizer use. During observations, surveyors saw the inhaler on the resident’s over-bed table, and the resident reported using it when needed, sometimes twice a day. On another observation, the resident was seen taking two puffs of the albuterol inhaler. When questioned, the CNO initially stated the resident had an assessment to self-administer the inhaler, but when the surveyor reported that no such assessment was found in the record, the CNO said she would look for it. The following day, the CNO stated she was unable to find any assessment indicating the resident had been evaluated to self-administer the inhaler, acknowledging that the resident should have had such an assessment.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that residents were initially assessed by the interdisciplinary team (IDT) to determine if they were safe to self-administer medications, as required by facility policy, for one resident. The facility’s Self-Administration of Medications policy, revised February 2021, stated that residents have the right to self-administer medications only if the IDT determines it is clinically appropriate and safe, and that such determinations must be documented in the medical record and care plan. During observation, a surveyor noted that Resident #35 had Calcitonin nasal spray on her overbed table; the resident reported that she kept it in her room for use when she needed it and that she had used it before coming to the facility. Review of the resident’s medical record and care plan showed no documentation of an IDT assessment or authorization for self-administration of medications. The Regional Nurse Consultant confirmed that the resident should not have had the Calcitonin nasal spray in her room and that no IDT assessment for self-administration had been completed.
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).
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to determine whether self-administration of medications was clinically appropriate for a cognitively intact resident on dialysis who was reviewed for self-administration of drugs. The resident had diagnoses including renal dialysis, end stage renal disease, gastrointestinal hemorrhage, and anemia, and the quarterly MDS showed the resident was cognitively intact with no behaviors. Despite this, the resident was not care planned for self-administration of medications, and there was no assessment in the electronic medical record regarding the resident’s ability to self-administer medications. The physician’s orders did not include naproxen sodium or lidocaine-prilocaine cream, nor did they include any order authorizing the resident to self-administer medications. Surveyor observation found an opened bottle of naproxen sodium 500 mg and four opened tubes of prescription lidocaine-prilocaine cream on the resident’s overbed tray table while the assigned medication aide was outside the room at the medication cart and unaware that these medications were present. The resident reported that he kept naproxen in his room to take for headaches and that he applied the lidocaine cream to his fistula prior to dialysis, stating that his responsible party had brought these medications from an outside pharmacy. The physician stated that the resident should not self-administer naproxen or lidocaine cream without supervision and that residents were to be assessed for safe self-administration. The unit manager and DON both confirmed that residents must be assessed for self-administration, require a physician’s order specifying which medications may be self-administered, must have medications stored properly, and must have the care plan updated, and both stated they were unaware that this resident was self-administering and keeping these medications unsecured in the room.
Failure to Assess Resident Before Leaving Medications at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for the ability to safely self-administer medications before leaving medications at the bedside unsupervised. The resident had a diagnosis of hemiplegia affecting the left nondominant side and an Annual MDS showing a BIMS score of 15, indicating intact cognition. However, the resident’s EMR contained no Self-Administration of Medications assessment, and the Baseline Care Plan did not address self-medication. Despite this lack of assessment and care plan direction, staff practice resulted in medications being left in the resident’s room. During observation, the resident was noted to have a pill cup with two pills on the bedside table and stated she had a question about what the pills were. When a licensed nurse entered, the resident asked what the pills were; the nurse stated one looked like Tylenol but would need to check on the other pill and then said she needed to ask the CMA who had placed and left the medications in the room. The nurse removed the pills to consult the CMA. The resident reported she had never been assessed to self-administer medications to her recollection. When interviewed, administrative staff stated that residents appropriate for self-administration would be identified in the care plan after provider notification and an order, and also stated that medications should not be left at the bedside, which contrasted with the observed practice and the facility’s own Medication Administration Policy referencing a Self-Administration Policy and Procedure.
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