Failure to Evaluate Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were evaluated for self-administration of medications, as required by 42 CFR part 483.10(c)(7). Specifically, two residents, identified as R114 and R12, were found to have medications at their bedside without proper assessment or physician's orders. Resident R114 had two containers of eye drops, latanoprost and brimonidine tartrate, which she kept at her bedside to maintain her home routine, citing inconsistent administration times by the nursing staff. However, there was no documentation in her clinical record indicating that she had been assessed for the capacity and ability to safely self-administer these medications. Similarly, Resident R12 had a tube of hydrocortisone cream at her bedside, which she used as needed for a rash on her leg. Like Resident R114, there was no evidence in her clinical record of an assessment for her ability to self-administer the medication safely. Observations and interviews with Employee E6, a licensed nurse, confirmed the presence of these medications at the residents' bedsides and the lack of necessary evaluations or physician's orders for self-administration. This oversight indicates a failure to comply with both federal and state regulations regarding resident rights and pharmacy services.
Plan Of Correction
1. R114 eye drops at bedside have been removed. R12 hydrocortisone cream was removed. No adverse effects were noted. 2. An initial audit was conducted to ensure medication is not at any residents bedside unless self administration evaluation was completed and residents were deemed safe to self administer. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. Licensed nursing staff were educated by DON/designee on policy of medication at bedside and self-administration. 4. DON/Designee will conduct audit on medication at bedside which will be completed 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.