Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safety of self-administration of medications for two residents, R811 and R812, as required by regulations. Resident R811, who was admitted with diagnoses including alcoholic cardiomyopathy, sarcoidosis of the lung, and depression, was observed with a Breo Ellipta inhaler on their overbed table. However, there was no care plan, physician order, or interdisciplinary assessment documented in the clinical record to support the self-administration of this medication. This was confirmed by the Unit Director RN during an interview. Similarly, Resident R812, re-admitted with conditions such as angina pectoris, cardiomyopathy, and intracardiac thrombosis, was found with Desenex powder, triamcinolone cream, and betadine bottles on their bedside table and windowsill. Like Resident R811, there was no documentation of a care plan, physician order, or interdisciplinary assessment for self-administration of these medications. The Director of Nursing confirmed the facility's failure to determine the safety of self-administration for these residents.
Plan Of Correction
1. R811 was assessed for ability to self-administer medications. Physician order was obtained and care plan was revised. Treatment creams and supplies were removed from bedside for R812. R812 is unable to self-administer treatments. 2. A house audit was done to ensure residents who have medications at bedside have proper assessments, orders and care plans. No issues identified. 3. Director of nursing or designee will in service licensed nurses on not leaving medications or treatments at bedside unless the resident has been assessed to safely self-administer and has physician order to do so. 4. Director of nursing or designee will audit 10 residents weekly for 2 weeks, then 5 residents weekly for 2 weeks, then 5 residents monthly for 2 months to ensure residents do not have medications or treatments left at bedside unless they have proper assessment and physician order to do so. Audit findings will be shared with QAPI committee.