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F0554
D

Failure to Assess Resident for Safe Self-Administration of Medication

Portland, Oregon Survey Completed on 04-28-2025

Penalty

Fine: $149,783
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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 resident admitted with dementia and no cognitive impairment documented on the most recent MDS was found to have Aspercreme lidocaine gel, a topical pain reliever, at their bedside within reach. The resident reported using the gel on their heels. Review of the health record showed that no assessment had been completed to determine the resident's ability to safely self-administer this medication. Multiple staff members, including CNAs and an LPN, confirmed the presence of the medication at the bedside and stated that medications should not be kept in resident rooms, but rather in medication carts. The regional clinical support staff also confirmed that no self-administration assessment had been performed and that the medication should not have been left in the resident's room.

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