Failure to Assess Resident for Self-Administration of Medication
Summary
The facility failed to determine if a resident was safe to self-administer medications, as required by their policy. The policy, dated July 2024, stated that residents were not allowed to bring medications from outside the facility and that medications should not be left in open view. However, an admission Minimum Data Set (MDS) assessment for the resident, dated July 31, 2024, showed no documented evaluation to determine the resident's capability to self-administer medications. The resident, who was cognitively intact and required supervision for care needs, was taking an antibiotic for cellulitis. Physician's orders indicated the resident was to receive Bactrim DS twice a day until July 27, 2024. On August 19, 2024, an observation and interview with the resident revealed a medication bottle labeled Bactrim DS from a hospital pharmacy on the over-bed table. The resident stated that the medication was from the hospital and that he had taken two tablets when the facility's medication system was not working. An LPN confirmed that medications should not be at the bedside and noted two tablets were missing from the bottle. A nursing note from July 24, 2024, indicated the resident was admitted with cellulitis and was to take Bactrim DS through August 27, 2024. The medication administration record showed the 8:00 p.m. dose on July 25, 2024, was not administered due to unavailability. The DON confirmed the resident had not been assessed for self-administration and the two missing pills could have been taken when the medication was unavailable.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Facility staff failed to follow self-administration protocols when an LPN left two 500 mg Tylenol tablets at the bedside of a resident with alcoholic cirrhosis, ascites, and GERD, who had mild cognitive impairment, after the resident requested pain medication. Later observations found a medicine cup with multiple colored tablets still on the overbed table, but the two oblong white tablets were no longer present and the resident was not in the room. Record review confirmed there were no physician orders for the medications found at the bedside and no orders or interdisciplinary assessment authorizing self-administration, despite facility policy requiring such assessment and orders before residents may self-administer medications.
A resident was found with an over-the-counter medication at the bedside and reported self-administering it daily without a documented assessment or physician order. Despite facility policy requiring an interdisciplinary team assessment for self-administration, staff confirmed that no such assessment or order was in place for any residents on the unit.
A resident undergoing chemotherapy was allowed to keep and self-administer an inhaler and pain ointments at the bedside without a prior assessment of their ability to do so safely. Staff interviews and record reviews confirmed that the required self-administration assessment and care plan updates were not completed before medications were left in the resident's room, contrary to facility policy.
Two residents were allowed to self-administer medications without a prior assessment or physician's order, as required by facility policy. An LPN left oral medications at the bedside for the residents to take unsupervised, and one resident was also found with an inhaler at the bedside without proper authorization. The DON and staff confirmed that no assessments or orders were in place, and the required procedures for self-administration were not followed.
A resident with chronic respiratory conditions was found to have an Albuterol inhaler and over-the-counter medications in their possession without documentation of an assessment for self-administration. The resident was cognitively intact and had a provider order for Albuterol as needed, but staff failed to document administration or assess the resident's ability to self-administer medications, contrary to facility policy.
A resident with multiple chronic conditions was found with a bottle of Polyethylene Glycol at the bedside without a documented self-administration assessment or physician order. Staff confirmed that no residents on the unit had such assessments or orders, and facility policy requires an interdisciplinary team determination for self-administration. The medication was being administered as ordered, but the presence of the bottle at the bedside without proper authorization led to the deficiency.
Medications Left at Bedside Without Self-Administration Assessment or Orders
Penalty
Summary
Facility staff failed to ensure it was clinically appropriate for a resident to self-administer medications when medications were left at the bedside without required assessment or physician orders. During an initial tour, surveyors observed a medicine cup containing seven colored tablets and two oblong white tablets on the overbed table of Resident #7, who was not in the room. Later the same day, during an evening tour, the medicine cup with the seven colored tablets remained on the overbed table, but the two oblong white tablets were no longer present, and the resident was again not in the room. Review of the clinical record showed that the resident had no active order for the medication found at the bedside and no order for self-administration of medications. Resident #7 had been admitted with diagnoses including alcoholic cirrhosis of the liver with ascites and gastro-esophageal reflux disease without esophagitis, and had a BIMS score of 13/15, indicating mild cognitive impairment. An interview with an LPN revealed that the resident had requested Tylenol after breakfast and was given two 500 mg Tylenol tablets at approximately 10:00 a.m.; the LPN stated the resident must have put them down instead of taking them as he said he would. The LPN also stated that medications should never be left at the bedside without a self-administration assessment and physician orders, and that no residents on the unit had such assessments or orders. Review of the facility’s Self-Administration of Medication and Treatments Policy showed that residents have the right to self-administer medications only if the interdisciplinary team has determined it is clinically appropriate and safe, which had not been done for this resident.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
Facility staff failed to ensure that a resident was properly assessed for self-administration of medication, as required by facility policy. During the survey, an over-the-counter bottle of Thera-Flu Max was observed at the bedside of a resident who reported self-administering the medication daily for congestion. The resident had a history of cerebral infarct, hemiplegia, cognitive communication deficit, and asthma, but demonstrated no cognitive impairment with a BIMS score of 15 out of 15 and required assistance with activities of daily living. Upon review, there was no documented assessment or physician order authorizing self-administration of the medication or allowing the medication to be kept at the bedside. Staff interviews confirmed that no residents on the unit had completed assessments or orders for self-administration of medications. Facility policy requires an interdisciplinary team determination for clinical appropriateness and safety before permitting self-administration, which was not completed in this case.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
Facility staff failed to assess a resident's ability to safely self-administer medications prior to allowing the resident to keep and use medications at the bedside. Observations revealed that the resident had an inhaler, CBD pain ointment, menthol pain ointment, and vitamin D3 stored in a basket at the bedside. The resident reported using the pain ointments for relief during chemotherapy and self-administering the inhaler twice daily, with the nurse leaving the inhaler in the room for the resident to use. Interviews with staff indicated that there was a process for approving self-administration, but in this case, no assessment had been completed before the medications were left at the bedside. Further review of the clinical record confirmed the absence of a self-administration assessment and that the resident's care plan did not address self-administration of medications. The Minimum Data Set did not indicate that the resident was independent with medications. Facility policy required an assessment to ensure residents could safely self-administer and store medications in a locked compartment, but these steps were not followed prior to the medications being left at the bedside.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
Facility staff allowed two residents to self-administer medications without conducting a prior assessment or obtaining a physician's order, as required by facility policy. Both residents were assessed as cognitively intact and had multiple medical diagnoses, including diabetes, asthma, atrial fibrillation, spinal stenosis, and hypertension. On the evening in question, an LPN prepared and left oral medications at the bedside for these residents to take upon returning to their rooms, without witnessing the administration or ensuring the medications were secured. The LPN stated this was done to expedite the medication pass, and later confirmed that one resident self-administered the medication while the other was observed taking it after the LPN returned to the room. Clinical record review revealed that neither resident had a physician's order or an interdisciplinary assessment authorizing self-administration of medications. Interviews with the DON and staff development coordinator confirmed that the facility's policy requires both an assessment and a physician's order before residents are permitted to self-administer medications, and that medications should not be left unattended at the bedside. The DON also stated that residents approved for self-administration are provided with a lock box for medication storage, which was not the case for these residents. Additionally, one resident was found with a Trelegy Ellipta inhaler at the bedside, which had been used, without a physician's order or assessment for self-administration. The resident reported self-administering the inhaler daily, and staff were unaware that the device was in the room. Facility policy requires a licensed nurse to assess the resident's ability to self-administer, with interdisciplinary team review and documentation in the medical record, none of which was completed for this resident.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
Facility staff failed to assess a resident for self-administration of medications, despite the resident having an Albuterol inhaler in their possession. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and heart failure, was found to be cognitively intact with a BIMS score of 15 out of 15. The resident's care plan included interventions for respiratory conditions, but there was no documentation indicating an assessment for self-administration of medications. The resident was observed keeping the inhaler in their pocket and stated they used it as needed for shortness of breath. Additionally, over-the-counter medications were found in the resident's bedside drawer, which were not on the medication list. A review of the clinical record revealed a provider order for Albuterol as needed, but there was no documentation on the medication administration record for its administration during the month in question. Facility policy required that residents be assessed by the interdisciplinary team for self-administration of medications and that unauthorized medications found at the bedside be given to the charge nurse. Despite these requirements, there was no evidence that the resident had been assessed for self-administration, and the issue was confirmed during a meeting with facility administrators.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
Facility staff failed to ensure that a resident was properly assessed for self-administration of medication, as required by policy. During an initial tour, a medication bottle of Polyethylene Glycol was found on the resident's nightstand, and the resident stated it was a prescription she had picked up before coming to the facility. There was no documentation of a self-administration assessment or a physician's order permitting the medication to be kept at the bedside. Both the RN and LPN interviewed confirmed that medications should not be left at the bedside without an assessment and physician order, and neither was aware of any such assessments or orders for residents on the unit. The resident in question had multiple diagnoses, including COPD, hypertension, chronic kidney disease, diabetes, acute respiratory failure, and congestive heart failure, and required assistance with activities of daily living. The clinical record showed an active order and scheduled administration for Polyethylene Glycol, which was being administered as ordered by staff. However, the presence of the medication at the bedside without proper assessment or order constituted a failure to follow facility policy and regulatory requirements regarding self-administration of medications.
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