Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed by the interdisciplinary team to determine their ability to safely self-administer medications. Resident #66 was observed with various medications in their room, including [MEDICATION NAME], Vitamin C, Men's Multivitamin, and Pepto-Bismol, which they self-administered without an evaluation or physician's order permitting them to do so. The facility's policy required an assessment and a physician's order for residents to self-administer medications, but this was not followed for Resident #66. Resident #66, who was cognitively intact and capable of making their own healthcare decisions, had a history of [DIAGNOSES REDACTED]. Despite this, there was no documented evidence in the care plan or medical records that Resident #66 had been evaluated for self-administration of medications. The resident had been purchasing medications online and self-administering them without the knowledge or approval of the nursing staff, who were unaware of the resident's actions until the survey. Interviews with the nursing staff revealed a lack of communication and oversight regarding Resident #66's medication management. Licensed Practical Nurses and the Registered Nurse Supervisor acknowledged that Resident #66 should not have had medications at their bedside without an order, and the Director of Nursing and Administrator expected that an order and care plan update should have been in place. The failure to assess and document Resident #66's ability to self-administer medications led to the deficiency identified during the survey.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action Taken for the Resident(s) Identified The medications were removed from resident #66, as resident already had physician orders [REDACTED]. Identification of Other Residents Who Could Be Affected A facility-wide audit to be conducted to identify other residents who would like to self-administer their medications. If residents are identified wanting to self-administer, they will be assessed by the interdisciplinary team for appropriateness. Systemic Changes to Prevent Recurrence - The Resident Self-Medication/Self-Treatment Instructions Policy was reviewed to ensure there are clear procedures for resident requests, assessments, care planning, documentation, and ongoing monitoring. - A new Self Administration Evaluation Tool for self-administration capability will be implemented and must be completed by the interdisciplinary team within 72 hours of a resident’s request. - All licensed staff to be re-educated on resident rights to self-administer medications, including the requirement for assessment and care plan updates. Monitoring and Quality Assurance - The Quality Assurance Director or designee will audit 10% of all resident records weekly for 8 weeks to ensure: - Proper assessments are completed - Care plans reflect the self-administration status - Medications are stored and administered in accordance with facility policy Results will be reviewed monthly by the Quality Assurance meetings, and corrective action will be taken immediately for any noncompliance. After 8 weeks, if 100% compliance is sustained, monitoring will continue monthly for an additional 3 months. Responsible Person: The Quality Assurance Director or Designee