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F0554
D

Failure to Assess and Authorize Self-Administration of Medications

Lumberton, North Carolina Survey Completed on 08-29-2025

Penalty

No penalty information released
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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

The facility failed to assess and authorize the self-administration of medications before leaving medications at the bedside for two residents. For one resident with type 2 diabetes mellitus and chronic kidney disease, there was no documented assessment or physician's order permitting self-administration of medication. The resident was noted to be severely cognitively impaired according to the Minimum Data Set (MDS) assessment. During an observation, medications including Metformin, Amlodipine, and Jardiance were left at the bedside in a medication cup at the resident's request, and the nurse acknowledged this was not in accordance with facility policy. The nurse was not aware of any assessment or care plan allowing self-administration and later reported the incident to the Unit Manager after realizing the error. Another resident, diagnosed with type 2 diabetes mellitus and unspecified dementia, also did not have a self-administration assessment or physician's order for self-administration of medications. This resident was cognitively intact per the MDS assessment. During an observation, a nurse left multiple medications at the bedside while briefly leaving the room to retrieve a blood pressure machine. The resident self-administered the medications in the nurse's absence. The nurse later confirmed that she left the medications at the bedside and stated she was not concerned due to the resident's alertness but did not follow the required assessment and authorization process. Interviews with the facility's Medical Director and Administrator confirmed that the expectation is for medication administration to be witnessed and that no residents were authorized to self-administer medications. Both staff members involved were unaware of any completed assessments or orders for self-administration, and the facility's process requires an assessment and interdisciplinary team review before permitting self-administration, which was not followed in these cases.

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