Failure to Prevent Unauthorized Self-Administration of Medication
Penalty
Summary
The facility failed to prevent a resident from self-administering medication despite explicit physician orders prohibiting this practice. Physician orders dated 4/14/25 specified that the resident was not permitted to self-administer medications. However, during observation and interview, the resident was found in possession of Zenpep Oral Capsule Delayed Release Particles and reported taking the medication independently whenever about to eat, without notifying nursing staff or documenting the administration. The resident also stated that this was the only medication kept personally, while all others were managed by nursing staff. Review of the Medication Administration Record (MAR) for May 2025 showed no documentation of the as-needed (PRN) doses of Zenpep from the start date through the date of the survey, despite an order for a maximum of 21 capsules per day. Facility staff, including the Administrator, Regional Director of Nursing, and President of Operations, confirmed that the resident was not supposed to self-administer Zenpep and acknowledged that the MAR did not accurately reflect the actual administration of the medication.