Failure to Evaluate Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was evaluated for safe self-administration of medications. Resident #5, who had intact cognition as per the Minimum Data Set (MDS) quarterly assessment, was observed with a medication cup containing various pills on her bedside table without staff supervision. Registered Nurse (RN) D later entered the room and asked the resident to take her medications, which she did. However, there was no physician order or plan of care documented for the resident to self-administer medications. RN D admitted to leaving the medications with the resident and stepping out of the room, which was against the facility's policy. The Unit Manager (UM) and Director of Nursing (DON) confirmed that medications should not be left at the bedside and must be administered under supervision. The facility's policy requires an interdisciplinary team to determine if a resident can safely self-administer medications, but this process was not followed for resident #5.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (a) Immediate action(s) taken for the resident(s) found to have been affected: The nurse ensured that Resident #5 took medications provided. The physician was notified of the incident, and no negative outcomes were identified. The nurse involved was re-educated on proper medication administration practices, including the requirement to observe the resident taking medications and ensure proper documentation. (b) Identification of other residents having the potential to be affected was accomplished by: All Residents have the potential to be affected. (c) Actions taken/systems put into place to reduce the risk of future occurrence include: Starting on all Licensed staff (RNs and LPNs) will receive mandatory training on medication administration policies, emphasizing the prohibition of leaving medications unattended. All Licensed staff will be in-service by. Any Licensed staff not in serviced by this date will be in-service prior to their next scheduled shift. We have no Agency staff currently. All newly hired Licensed staff will be in-service by the ADON during their orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur: The DON or designee will conduct weekly audits of medication administration with 2 nurses for at least 2 Residents 3 times a week for 2 weeks, then at least 8 Residents monthly for three months to ensure adherence to the policy. Any non-compliance identified will result in immediate re-education and corrective action. Audit findings will be reviewed during the facility's monthly Quality Assurance and Performance Improvement (QAPI) meetings. (e) Date of compliance: