Failure to Obtain Orders and Ensure Safe Storage for Self-Administered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who was assessed as clinically appropriate to self-administer medications had a physician’s order to self-administer or store medications at bedside before doing so, and to ensure the medications were stored safely and securely. The resident was admitted with cirrhosis of the liver, diabetes mellitus, and chronic respiratory failure with hypoxia. An MDS assessment showed the resident could make herself understood and understand others, required supervision or touching assistance with eating, moderate assistance with oral hygiene, and maximal assistance with bed mobility and transfers. A Self-Administration of Medication (SAOM) assessment completed by an RN on 2/2/2026 indicated the resident was fully capable of storing medications in a secure location and safely self-administering them. On observation in the resident’s room, surveyors saw bottles of XyliMelts and Biotene oral gel on top of the bedside table, accessible in the open. The resident stated she needed to take medications, pointed to these products, and reported that she took them whenever she needed to and kept them on top of her bedside table. When asked if she had been instructed to call a nurse before taking the medications, she stated that the nurses knew she was taking them. During a subsequent observation with an LVN, the same medications were again seen on top of the bedside table, and the resident was observed taking a XyliMelts tablet while the LVN was out of the room. The LVN reported he was not aware the resident was self-administering or storing these medications at bedside and, upon checking, found no physician’s orders authorizing self-administration or bedside storage at that time. The RN who completed the SAOM assessment acknowledged that she had assessed the resident as alert and oriented and able to correctly demonstrate how and when to take the XyliMelts and Biotene oral gel, and had documented that the resident was capable of safe self-administration and secure storage, but she did not notify the physician or obtain the required orders on the day of the assessment. The ADON confirmed that the SAOM was completed without obtaining physician orders for self-administration or bedside storage and stated that medications should be stored in a secure location, noting that leaving medications on the bedside table could allow cognitively impaired residents access to them. Facility policies on self-administration and administering medications required that self-administered medications be stored in a safe and secure place not accessible by other residents and that medications be administered as prescribed.
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