Failure to Assess and Document Resident's Self-Administration of Medications
Summary
A deficiency was identified when a resident was observed with a medication cup containing multiple medications at their bedside and proceeded to self-administer these medications without the presence of a licensed nurse. The resident's medical record did not contain an assessment, physician's order, or care plan addressing the ability to self-administer medications. The facility's policy requires that the interdisciplinary team (IDT) assess the safety of self-administration, clarify physician orders to include "may keep at bedside," and document these determinations in the care plan, none of which were completed for this resident. Interviews with facility staff, including an LVN and the DON, confirmed that the resident was not supposed to have medications unattended at the bedside and that the required assessment and documentation were missing. The medications involved included blood pressure medications, blood thinners, and supplements. The DON verified that the resident's records lacked the necessary assessment, physician's order, and care plan problem for self-administration of medications, in direct violation of facility policy and federal requirements.
Plan Of Correction
Corrective Action for those residents identified as being affected by this deficiency: Resident 3 was assessed by the DON if he wishes to self-administer medications on 7/24/2025 and resident declined. Identification of other residents having the potential to be affected by this same deficiency: All residents have the potential to be affected by the same deficiency. On 8/1/25, facility angel rounds members conducted an audit of the residents who wish to self-administer medications and found no concerns. Measures that will be put into place to ensure that this deficient practice does not recur: On 7/24/25, DON conducted an in-service with the licensed staff on the Policy and Procedures on Medication Pass and Self Administration Assessment and will be completed by 8/11/25. On 7/24/25, a one-on-one in-service was conducted by the DON to LVN I regarding Policy and Procedures on Medication Pass and Self Administration. A medpass skills check is scheduled with LVN I on 8/7/25 by the DON and/or designee. Facility angel rounds members will continue room rounds 5x/wk with emphasis on medications left unattended at bedside starting the week of 8/4/25 for 4 weeks. Any findings will be forwarded to the DON for action planning. On 8/1/25, facility angel rounds members conducted an audit of the residents who wish to self-administer medications and found no concerns. Measures that will be put into place to ensure that this deficient practice does not recur: On 7/24/25, DON conducted an in-service with the licensed staff on the Policy and Procedures on Medication Pass and Self Administration Assessment and will be completed by 8/11/25. On 7/24/25, a one-on-one in-service was conducted by the DON to LVN I regarding Policy and Procedures on Medication Pass and Self Administration. A medpass skills check is scheduled with LVN I on 8/7/25 by the DON and/or designee. Facility angel rounds members will continue room rounds 5x/wk with emphasis on medications left unattended at bedside starting the week of 8/4/25 for 4 weeks. Any findings will be forwarded to the DON for action planning. How the facility will monitor its performance to make sure that solutions are sustained: Documented findings of the audit will be forwarded to the QAPI committee monthly for at least 4 weeks beginning September 2025 for review and action planning as indicated or as the QAPI committee determines compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with intact cognition and multiple diagnoses, including AFib, HF, stroke, anxiety, and depression, was permitted to self-administer nebulizer treatments after staff setup without an IDT self-administration assessment. The EMR lacked documentation of the resident’s competency and safety to manage the nebulizer, including understanding the medication, following directions, operating the equipment, recognizing side effects, and storing the medication and equipment. Staff and the DON confirmed the assessment had not been completed before the self-administration order was implemented.
Unsafe bedside medication storage and self-administration were identified for two residents. One resident with COPD and OSA had an unlabeled inhaler and chewable tablets left at the bedside even though she was not assessed as safe for SAM and had no order allowing bedside storage. Another resident, who was also not safe for SAM and had a history of hoarding OTC medications, had Biofreeze left at the bedside and was observed applying it herself. Staff and facility policy stated bedside medications were only allowed when a resident was assessed as safe for SAM and had the proper provider order.
A resident with paraplegia and cognitive communication deficit, but assessed as cognitively intact, was observed keeping and self-applying labeled nystatin cream at bedside and self-administering other medications left in a cup per physician order. The care plan stated the resident could self-administer medications and required quarterly assessments, and a prior self-administration review months earlier had approved several oral supplements and a sleep aid for unsupervised self-administration. However, no subsequent self-administration assessments were completed, contrary to the facility’s policy requiring quarterly interdisciplinary reassessment to ensure medications remained appropriate and safe for self-administration.
Surveyors determined that a resident with multiple complex conditions, including quadriplegia, emphysema, and sleep apnea, was self-administering a prescribed Proventil HFA (albuterol) inhaler kept at the bedside without a documented self-administration of medication assessment. Record review confirmed the absence of the required assessment, and the DON acknowledged that the resident should not have been self-administering medication without it. This failure created the potential for harm if the resident took too much or too little of the inhaled medication or experienced adverse effects such as oral thrush.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
A resident with mild cognitive impairment, multiple medical diagnoses, and a physician order for scheduled DuoNeb nebulizer treatments was repeatedly observed using the nebulizer without staff present, including times when the mask lay on the bed or floor while the machine was running or was held far from the mouth. The care plan documented impaired cognition and the need for supervision and task segmentation, and an intervention to administer treatments as ordered, yet there was no documented self-medication assessment, no care plan direction for self-administration, and no physician order authorizing self-administration, contrary to facility policy requiring an IDT assessment and documentation before allowing self-administration of medications.
Missing Self-Administration Assessment for Nebulizer Use
Penalty
Summary
The facility failed to ensure an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer nebulizer treatments. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders showed Ipratropium-Albuterol nebulizer treatments three times daily, and the EMR later included an order permitting the resident to self-administer nebulizer treatments after staff setup, but there was no evidence that an IDT self-administration assessment had been completed first. The record also lacked documentation showing the resident’s competency and safety to self-administer the nebulizer medication and treatment, including the ability to understand the medication purpose, follow directions, safely operate the equipment, recognize side effects or adverse reactions, and ensure safe administration and storage. During observation, the resident had nebulizer equipment and medication available in the room. The resident stated staff set up the medication cup and left while the treatment ran, then returned to ensure the machine was turned off; staff cleaned the nebulizer mask afterward. An LPN and RN confirmed the treatment was set up by staff, and the RN and DON stated a self-administration assessment should have been completed before the resident was permitted to self-administer medications.
Unsafe Bedside Medication Storage and Self-Administration
Penalty
Summary
The facility failed to ensure medications were administered safely for 2 residents who had been assessed as unable to safely self-administer medications. One resident had COPD, OSA, and a functional decline related to a right scapula and rib nonunion. Her care plan and provider orders included calcium carbonate antacid, but the EMR lacked orders allowing self-administration or bedside medication storage, and her SAM assessment indicated she did not want to self-administer medications and agreed to have them administered by the facility. During observation, she had an unlabeled inhaler and a cup with two chewable tablets on her bedside table, and an LPN confirmed the medications were a Symbicort inhaler and Tums that should not have been left at the bedside because she was not assessed as safe for SAM. The second resident’s quarterly MDS indicated cognitive intactness, but provider orders stated she may not self-administer medication, and the SAM assessment indicated she was not safe to self-administer medications and had hoarded and used multiple OTC medications. Despite this, Biofreeze topical analgesic was observed in a bin on her bedside table on multiple occasions, and the resident stated she applied it herself. A nursing assistant confirmed the Biofreeze was in the room because the resident used it when needed. Staff interviews and facility policy stated medications should not be left at the bedside unless the resident had been assessed as safe for SAM and had the required provider order.
Failure to Complete Required Quarterly Self-Administration Medication Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete required quarterly assessments for a resident who was permitted to self-administer medications per the care plan and facility policy. Surveyors observed a tube of nystatin cream with a medication label on the bedside table of a resident with diagnoses including paraplegia and cognitive communication deficit; the resident stated she applied the cream herself and knew how to use it. The nystatin cream was again observed at the bedside on a subsequent day. The resident’s Quarterly MDS indicated she was cognitively intact but had limited range of motion in both upper and lower extremities. A prior Medication Self-Administer Review dated several months earlier documented that the resident was able to self-administer several oral supplements and a sleep aid unsupervised. Record review showed no additional self-administration assessments had been completed after the November assessment, despite a care plan initiated in early January stating the resident was able to administer medications to herself and directing staff to assess her for self-administration of medications quarterly. Physician’s orders included nystatin cream to be applied to the groin twice daily and as needed, and an order allowing the resident to self-administer medications brought to her by nursing staff, with the resident requesting pills be left in a cup at the bedside. During interview, the DON confirmed there were no other self-administration assessments completed. The facility’s Self-Administration of Medication policy required that medications be assessed for appropriateness and safety for self-administration and that the interdisciplinary team conduct reassessments quarterly and with any significant change in condition to ensure safe self-administration remained feasible.
Failure to Assess Resident for Self-Administration of Inhaler Medication
Penalty
Summary
Surveyors found that the facility failed to complete a self-administration of medication assessment for a resident who was self-administering an inhaler. The resident had multiple diagnoses, including quadriplegia, muscle weakness, a stage 4 pressure ulcer of the right buttock, anxiety, depression, emphysema, and sleep apnea, and had been readmitted to the facility with a physician’s order for Proventil HFA (albuterol sulfate) inhalation aerosol, 2 puffs by mouth every 4 hours as needed for shortness of breath, with instructions to rinse the mouth after use. During observation, the resident’s inhaler was seen on the bedside table, indicating self-administration, but review of the medical record showed no documented self-administration of medication assessment. In an interview, the DON confirmed that the resident should not have been self-administering medication without such an assessment and acknowledged that the assessment should have been completed. This deficient practice created the potential for harm if the resident took too much or too little of the inhaled medication, or suffered adverse effects such as oral thrush, due to lack of assessment. The deficiency was cited under the requirement to allow residents to self-administer drugs only when clinically appropriate and after proper assessment, and it was cross-referenced to F761.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Assess and Authorize Self-Administration of Nebulizer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to assess and authorize a resident for self-administration of a prescribed nebulized medication despite repeated observations of the resident using the nebulizer without staff present. The resident had a physician’s order for DuoNeb via nebulizer four times daily at scheduled times and had a BIMS score of 12/15, indicating mild cognitive impairment, with diagnoses including anxiety, depression, asthma, history of stroke, drug use, and metabolic encephalopathy. The MDS indicated the resident was dependent on staff for all ADLs except needing substantial/maximal assistance for eating, and the care plan documented impaired cognitive function and the need for cueing, orientation, supervision, and task segmentation. The care plan also included a problem area for infection risk with an intervention to administer treatments as ordered. Surveyors observed multiple instances where the nebulizer treatment was running without appropriate staff administration or supervision. On one occasion, the nebulizer machine was on with DuoNeb solution in the chamber and mist exiting the face mask, which was lying on the bed while the resident lay flat, with no staff present. On another observation, the resident was in bed holding the nebulizer mask about 20 inches from his mouth with the machine running, and later the mask was on the floor with the machine still on, again with no staff present. A further observation showed the resident in bed with the nebulizer mask on his face and no staff present. A nurse stated she had to go back to check on the resident because he had a history of taking the nebulizer mask off during treatment. Review of the clinical record showed no self-medication administration assessment, no care plan direction addressing self-administration of the DuoNeb nebulizer treatment, and no physician order authorizing self-administration, despite facility policy requiring an interdisciplinary assessment and documentation before allowing self-administration of medications.
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