Failure to Assess and Document Resident's Self-Administration of Medications
Penalty
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.