Failure to Conduct Medication Self-Administration Assessments
Penalty
Summary
The facility failed to conduct medication self-administration assessments for two residents, leading to a deficiency in ensuring the safety of self-administered medications. Resident #49, who was cognitively intact with a BIMS score of 15, was found with various herbal supplements and vitamins at his bedside, which he was taking without a physician's order or a completed self-administration evaluation. The resident had stopped taking Gabapentin, a prescribed medication, in favor of the herbal blend, yet there was no documentation or approval for this change in his medication regimen. Similarly, Resident #305, with a BIMS score indicating moderate cognitive impairment, was observed with Tylenol at his bedside, which he used for arthritis pain. Like Resident #49, there was no physician's order or self-administration evaluation for the Tylenol. The Director of Nursing confirmed that neither resident had been evaluated for medication self-administration, which is required by the facility's policy to prevent overdose and ensure safe medication practices.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or the conclusions set forth in the Statement of Deficiencies rendered by the reviewing agency. The Plan of Correction is prepared and executed solely because it is required by the provisions of federal and state law. Avante at Melbourne maintains the alleged deficiencies do not individually jeopardize the health and/or safety of its residents nor are they if such character as to limit the provider's capacity to render adequate resident care. Furthermore, Avante at Melbourne asserts that it is in substantial compliance with regulations governing the operation of long-term care facilities, and this Plan of Correction in its entirety constitutes the provider's credible allegation of compliance. A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On DON completed self-administration assessment for resident number 49. Reviewed with physician, physician declined self-admin order to add supplements to MAR stated the herbs may have contraindication with scheduled medication. b. Resident number 305 discharged from facility, readmitted declined self-administration assessment. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Audit completed on residents to ensure any resident who wished to self-administer medications has a self-administration screen completed along with a physician order to self-administer. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Director of Nursing/designee to complete education with Licensed Nurses to ensure residents who wish to self-administer medications have an assessment, lock box, MAR, and physician order. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit of residents who wish to administer medications by themselves have an assessment, lock box, MAR and physician order to do so weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.