Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly evaluated and assessed for self-administration of medications, and did not obtain physician orders or update care plans as required. Multiple residents were observed with medications and supplements at their bedside and reported self-administering these without documented assessments or orders permitting them to do so. Staff interviews confirmed that the required assessments and orders were not completed, and that medications should not have been accessible to residents without these steps. For example, one resident was found with multiple bottles of supplements at their bedside and in their drawer, and stated they took them daily, but there was no documentation of an assessment for self-administration. Another resident was observed using an albuterol inhaler from their nightstand and reported long-term use without ever being assessed for self-administration. Staff confirmed that neither an order nor an assessment was present for these residents, and that this was not in line with facility policy. Additional residents were found with prescription medications such as inhalers and nasal sprays at their bedside, self-administering them without completed assessments, physician orders, or care plan documentation. In several cases, the self-administration evaluation forms were blank or incomplete. Staff, including LPNs, Resident Care Managers, and the Director of Nursing, acknowledged during interviews that the required processes had not been followed and that medications should not have been accessible to residents without proper assessment and documentation.