Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess the ability of four residents to self-administer medications, as required by regulations. The interdisciplinary team did not determine whether self-administration was clinically appropriate for these residents, and there were no physician's orders or care plans addressing self-administration of medications. Additionally, there was no documentation of a Self-Administration of Medication assessment in the clinical records of these residents. Observations revealed that residents had medications in their rooms without supervision. One resident had a tube of Icy Hot cream, another had a cup of pills, and two others had bottles of Flonase nasal spray on their overbed tables. Interviews with staff confirmed that these medications were present in the residents' rooms and were removed by the staff. The Director of Nursing acknowledged the facility's failure to assess the residents' ability to self-administer medications.
Plan Of Correction
Residents #14, #42, #74, and #80 had not negative outcomes. Items left at bedside were secured and medications were administered to Resident #42. To identify other potential areas of concern, the DON/Designee completed a whole house audit of resident rooms to ensure medications were not left at bedside. The DON/designee will complete a house audit of residents with a BIMS of 13 or greater to see if any request to self-med administer. If so, the self-med assessment will be completed as appropriate. There were no negative findings. To prevent this from recurring, the DON/designee educated licensed nursing staff on the regulatory requirements of F554 regarding self-administration and also educated on the medication administration policy. To monitor and maintain ongoing compliance, the DON/designee will complete 3 room audits weekly x4, then monthly x2 to ensure no medications are left at bedside. Negative findings will be addressed, and ad hoc education will be completed as necessary. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.