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F0554
D

Failure to Assess Residents for Self-Administration of Medication

Baltimore, Maryland Survey Completed on 07-07-2025

Penalty

Fine: $484,200
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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

Surveyors observed that the facility failed to assess residents for their ability to self-administer medications. During a tour of one unit, surveyors found medication cups containing multiple pills left at the bedsides of two residents. In one instance, a medication cup with seven pills was found on a bedside table, and the resident explained that the nurse left the medication there because the resident needed to use the bathroom. The resident then took the medication in the presence of the LPN. In another instance, a resident was found with a medication cup containing six pills at the bedside and stated they had been distracted and would take the medication now. Interviews with LPNs revealed that medications were given to residents and they were supposed to be watched while taking them, but no narcotics were left at the bedside. Review of the medical records for both residents showed they were cognitively intact and able to make their own medical decisions, but there was no documented assessment or evaluation in the records to determine their ability to self-administer medication without nursing supervision.

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