Unassessed Self-Administration and Unsupervised Medications Left in Resident Room
Penalty
Summary
The facility failed to ensure a resident was properly assessed and authorized to self-administer medications before leaving medications unsupervised in the resident's room. During observation, two pill cups were found on the resident's dresser. One cup, labeled with the resident's name, contained an unmarked small white pill. The second, unlabeled cup contained a large piece of candy, an unmarked small white pill, a yellow capsule, and a large white tablet. An LPN compared the pills in the cups to the resident's medications and identified them as melatonin 5 mg, gabapentin 300 mg, and gabapentin 600 mg, and stated the medications should not have been left in the room. Record review showed the resident had diagnoses including chronic pain and neuropathy and was cognitively intact per an annual MDS assessment. Physician orders included gabapentin 300 mg twice daily, gabapentin 600 mg at bedtime, and melatonin 5 mg at bedtime. However, the clinical record did not contain a self-medication administration assessment or a physician's order authorizing the resident to self-administer medications. The facility's policy on self-administration of medications required completion of a self-administration assessment and a physician's order specifying the resident's ability to self-administer, but these were absent in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.