Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents could safely self-administer medications when clinically appropriate, as evidenced by observations and record reviews during a recertification survey. Two residents, identified as Resident #35 and Resident #168, were involved in this deficiency. Resident #35, who has diagnoses including Spina Bifida, morbid obesity, and paraplegia, was observed with a Proventil inhaler on their overbed table without documented evidence of an assessment for their ability to self-administer medications. Additionally, there was no physician order allowing self-administration, and the care plan did not include documentation for self-administration. Despite a physician order indicating the inhaler could be kept at the bedside, the Medication Administration Record stated that medications should not be left at the bedside, highlighting a discrepancy in the facility's adherence to its own policies. Resident #168, with diagnoses of chronic obstructive pulmonary disease, end-stage renal disease, and chronic systolic heart failure, was observed changing their oxygen tank and setting the flow rate independently. Similar to Resident #35, there was no documented assessment or physician order for self-administration of medications, and the care plan lacked documentation for self-administration. Interviews with facility staff, including a Certified Nurse Aide, LPN, and RN, revealed that residents were not permitted to change their own oxygen tanks or adjust flow rates, as oxygen is considered a medication. The staff acknowledged that residents should be assessed for self-administration and self-regulation of medications, but no such assessment was documented for Resident #168. The facility's Medication Self-Administration Policy, dated September 2017, requires staff and practitioners to assess each resident's mental and physical abilities to determine the appropriateness of self-administering medications. However, the facility failed to adhere to this policy for both residents involved in the deficiency. Interviews with the Assistant Director of Nursing confirmed that a care plan and assessment should be in place for residents to self-administer medications, but these were not completed for the residents in question.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. Residents #35 and #168 were assessed for safety in self-administering associated medication (inhaler and oxygen respectively) with medical orders provided if indicated and care planned accordingly. #35 medication is no longer left at bedside. #168 is not allowed to self-regulate oxygen or change tank per facility policy. 2. All resident medication administration records will be reviewed to identify orders which allow medication(s) to be left at bedside, and corresponding self-administration assessments. No other residents were identified which had medications at bedside without corresponding assessments and medical orders. All residents on oxygen reviewed to identify any resident that was independently changing supply or adjusting flow rates independently – no other residents identified. 3. All medical providers and Registered Nurses (RNs) will be re-educated on facility policy regarding self-administration of medication for residents, including assessment, medical orders and care planning requirements. No policy changes were indicated following review. 4. All new medication orders stating “self-administration” identified during the pharmacist’s monthly medication regimen review process will be reviewed to assure appropriate protocols (including assessment, medical order and care plan) are followed. Review to consist of 100% new orders for 3 months; and no less than 50% for the next 3 months; frequency to be re-evaluated at 6 months by Quality Assurance and Performance Improvement Committee based on overall compliance with policy. Responsible Party: Director of Nursing