Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
Corner View Nursing and Rehabilitation Center was found to be non-compliant with the requirement for residents to self-administer medications only when deemed clinically appropriate by the interdisciplinary team. The facility failed to assess the ability of two residents to safely self-administer their medications. Resident R143, who has diagnoses including non-Alzheimer's dementia, seizure disorder, and schizophrenia, was observed with a medication cup containing lactulose on their overbed table without an order for self-administration. The resident's care plan did not include goals or interventions for self-administration, and no assessment was completed to determine their ability to self-administer medications. Similarly, Resident R318, diagnosed with high blood pressure, atrial fibrillation, and heart failure, was found with an albuterol inhaler on their nightstand. There was no order for self-administration, and the resident's care plan lacked goals or interventions for self-administration. An assessment to determine the resident's ability to safely self-administer medications was not completed. The Director of Nursing confirmed the facility's failure to assess the ability of these residents to self-administer medications.
Plan Of Correction
The medications for Residents R143 and R318 were immediately removed from the resident's room. An assessment of both residents was completed to determine whether they could safely self-administer medications. An initial audit will be completed by DON/designee of current resident rooms to ensure there are no unsecured medications and that there is a self-administration of medication assessment completed for any resident self-administering his/her own medications. Licensed nursing staff re-education will be conducted by the DON/designee on self-administration of medications by a resident. The DON/designee will complete an audit of 5 medication passes specific to nurses leaving meds at bedside for 2 weeks, then 5 medication passes monthly for 2 months to ensure there are no medications left at bedside without an order. Results of audits will be reported by DON/designee monthly to the Quality Improvement Committee (QIC) for review and recommendation then randomly thereafter as determined by the QIC committee.