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F0554
D

Failure to Assess Residents for Safe Self-Administration of Medications

Burlington, Wisconsin Survey Completed on 05-08-2025

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

The facility failed to assess two residents for their ability to safely self-administer medications that were observed at their bedsides. One resident, admitted with a left ischium wound and determined to be cognitively intact, had a tube of Santyl ointment at the bedside and reported applying it as needed. Review of the resident's medical record showed no evidence of an assessment for safe self-administration of the medication. An LPN confirmed the medication was left at the bedside and was unaware of any assessment having been completed. Another resident, also cognitively intact and admitted with shortness of breath, was found with an Albuterol inhaler at the bedside. The resident stated she had been assessed for safe use of the inhaler, but review of the medical record did not show any such assessment, nor was there a physician order for the inhaler. The ADON confirmed that no safety assessment had been completed for this resident regarding self-administration of the inhaler, despite the resident having access to it for the past month.

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