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F0554
D

Medication Storage at Bedside Without Self-Administration Approval

Duluth, Minnesota Survey Completed on 04-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with diagnoses of dementia and Parkinson's disease, who had intact cognition but was not approved for self-administration of medication, was found to have a bottle of nystatin powder at their bedside on two separate occasions. The resident's Self Administration of Medication (SAM) assessments indicated that the resident could not identify the expiration date of medications and either did not want to or was unable to self-administer medications. The care plan lacked documentation related to the SAM assessment. Interviews with nursing staff, including an LPN, RN, and the DON, confirmed that facility policy required a completed SAM assessment and a provider order before a resident could self-administer or keep medications at bedside. Despite this, the medication remained accessible to the resident, contrary to policy and assessment findings. The facility's policy stated that if a resident was not safe to self-administer, nursing staff would administer the medications, but did not address storage of medications at bedside for residents not cleared for self-administration.

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