Failure to Assess and Order Self-Administration of Medications
Summary
The facility failed to ensure residents were assessed for self-administration of medications and had physician orders permitting self-administration for 5 of 5 residents reviewed. Resident P, who was cognitively intact and had diagnoses including type 2 diabetes, anxiety, and a sacral pressure ulcer, was observed with a bottle of Rolaids on her overbed table. The resident stated she needed the Rolaids for stomach problems, but the record showed no self-administration assessment, no care plan related to self-administering medications, and no physician order for self-administration. The order in the chart was for calcium carbonate as needed for indigestion, but not for the resident to self-administer it. Resident 161 was observed with a plastic medication cup containing five pills left on a windowsill after the nurse had handed him the cup and left the room. He stated the nurse had initially brought his pills during breakfast, returned later, and left the medication with him after he told her to come back when he was finished eating; he then took only five pills and left the rest for later. His record showed diagnoses including type 2 diabetes, stroke, high blood pressure, heart disease, and dementia with moderate anxiety, but there was no self-administration assessment or physician order for self-administration. Resident 155 was observed with a cup containing eight pills on the nightstand while she was in the bathroom, and the cup was later taken to the nurse’s station and returned to the room for administration. Her record showed diagnoses including heart disease, anorexia, major depressive disorder, high blood pressure, and anxiety, and although a prior self-administration assessment said she could self-administer medications, it did not specify which medications and there was no order for self-administration before the observation. Resident Q stated that nurses often left his pills in a cup on the table and left the room, so he did not know what he was taking. His record showed diagnoses including Parkinson’s disease, emphysema, dementia, dysphagia, heart disease, high blood pressure, and anxiety disorder, and there was no order or assessment for self-administration. Resident X was observed self-administering an inhaler after an LPN placed it on the bedside table and left the room; the LPN later returned, removed the inhaler, and took it back to the medication cart. The resident’s record showed chronic respiratory failure and blindness, and there was no self-administration assessment or physician order for self-administration. The DON stated that a resident needed to be assessed as safe to self-administer medications before being allowed to do so, and the facility policy stated that the interdisciplinary team must determine that self-administration is clinically appropriate and identify which medications may be self-administered.
Penalty
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A resident who was cognitively intact had unlabeled hydrocortisone cream and antifungal powder at the bedside and said staff had given them to him for PRN use. The record lacked provider orders and any self-administration assessment for the topical medications, and staff gave conflicting accounts about whether the resident was allowed to keep and use them. The care plan also did not address bedside storage or self-administration of these medications.
A resident with moderate cognitive impairment, type 2 DM, and dementia self-administered Insulin Lispro even though there was no order or care plan documentation for self-administration. An LPN verified the medication, prepared the insulin, and handed the syringe to the resident, who injected it near the elbow. The DON confirmed no competency assessment had been completed.
A resident with anemia, MS, and a seizure disorder was found with Diclofenac cream, Biotin mouth wash, and Systane eye drops left on the bedside table even though the SAM evaluation and care plan stated the resident could not self-administer medications or keep them at bedside. The active order summary had no bedside-medication orders, and an LPN and RN both acknowledged the medications should not have been left in the room.
A resident with moderately impaired cognition had Cortisone 10 and Hempvona cream kept at the bedside and used them without a self-administration assessment or physician order. Staff confirmed no medications were to be left in the room, the care plan did not show self-administration, and the DON verified there was no assessment or order authorizing the creams to be stored and used in the room.
Failure to assess residents for self-administration of medications. Two residents were observed handling prescribed medications without the required Interdisciplinary Team assessment documented. One resident with paraplegia, Parkinson’s disease, and chronic pain syndrome had topical medications left unsecured at the bedside and stated he self-administered them as needed. Another resident with dementia, hallucinations, mild cognitive impairment, atrial fibrillation, and HTN was observed taking scheduled meds in his room without a nurse present, despite a physician order stating he may not administer his own medications. The DON confirmed neither resident had been assessed per policy.
Failure to assess clinical appropriateness for self-administration of meds. A cognitively intact resident with CHF, COPD, OSA, and other diagnoses was observed with pills left at the bedside, but the care plan and self-medication assessment only approved nasal spray and cough drops. Staff could not find an order allowing self-administration of the resident’s prescribed meds, yet medication was still left at the bedside and taken without clear verification.
Failure to Assess Self-Administration of Topical Medications
Penalty
Summary
The facility failed to ensure that self-administration of medications was assessed and determined to be appropriate for one resident who was cognitively intact and required varying levels of assistance with activities of daily living and mobility. The resident’s diagnoses included bilateral subdural hematomas related to a fall, congestive heart failure, hypertension, atrial fibrillation, and chronic kidney disease. The resident’s care plan did not identify interventions related to bedside storage or self-administration of topical medications, and the medical record lacked provider orders for 1% hydrocortisone cream and 2% miconazole nitrate powder, as well as any assessment showing that self-administration was appropriate. During observation, an open container of 1% hydrocortisone cream and a bottle of 2% miconazole nitrate antifungal powder were seen on the resident’s bedside table without pharmacy prescription labels. The resident stated that staff had given him the cream and crotch powder and that he was allowed to use them as needed. Staff interviews showed conflicting understanding about whether the medications should be in the room, whether orders existed, and whether a self-administration form had been completed. One LPN stated that the resident should not be self-administering anything because no completed self-administration form was found, while the DON stated that all residents were expected to be assessed before self-administering medications and that provider orders were expected for any self-administered medications.
Resident Self-Administered Insulin Without Competency Assessment
Penalty
Summary
The facility failed to ensure that a resident who self-administered medication was competent to do so. Resident 5 had a BIMS score of 10, indicating moderate cognitive impairment, and diagnoses of type 2 diabetes mellitus and unspecified dementia. The resident’s clinical profile listed a responsible party, and the care plan addressed insulin-dependent diabetes with an intervention to administer medications as ordered. The care plan did not include any information that the resident self-administered medications, and the order summary did not contain an order for self-administration. During an observation, the resident self-administered Insulin Lispro. The LPN verified the resident, medication, route, dose, and time, removed the insulin vial from the medication cart, and drew up 4 units of insulin. The LPN then gave the resident an alcohol wipe, which the resident used near the elbow, and handed the resident the insulin syringe, which the resident injected near the elbow. The DON later confirmed that no assessment had been completed to determine whether the resident was competent to self-administer medications.
Failure to Follow SAM Evaluation for Bedside Medications
Penalty
Summary
The facility failed to follow a self-administration of medication (SAM) form that indicated a resident could not self-administer medications and could not keep medications at bedside. The resident had diagnoses including anemia, multiple sclerosis, and seizure disorder. The quarterly MDS indicated no cognitive impairment, and the care plan stated the resident was unable to self-administer medications, with interventions for nursing to document, administer, and store all medications. The resident’s active order summary lacked orders to keep medications at bedside. Despite the SAM evaluation dated 8/21/25 stating the resident could not self-administer medications, a tube of Diclofenac muscle cream, Biotin mouth wash, and Systane eye drops were observed on the resident’s bedside table on 7/27/26 and again on 7/30/26, with no staff present in the room. An LPN stated a SAM assessment and provider orders were needed before leaving medications at bedside and confirmed the medications were left in the room, while an RN reviewed the SAM assessment and acknowledged the resident should not have medications left at bedside. The DON stated staff were expected to ensure the SAM assessment and related paperwork were completed and accurate before leaving medication at bedside.
Unassessed Self-Administration of Topical Medications
Penalty
Summary
Failure to allow resident self-administration of medications only after clinical determination and proper authorization occurred for one sampled resident who had Cortisone 10 and Hempvona cream on his bedside table. During an observation and interview, the resident stated he used the Cortisone 10 for facial itching and the Hempvona cream for discomfort, and he did not know whether staff knew he had them. A later observation again found both creams in the room. The resident’s EMR showed he was admitted to the facility, had a BIMS score of 12 indicating moderately impaired cognition, and had no medication self-administration assessment completed to determine whether he could safely self-administer the observed creams. The resident’s care plan did not indicate that he self-administered medications, and there was a physician’s order for Hempvona cream to be applied topically PRN but no physician’s order for Cortisone 10 cream. Staff interviews confirmed there was no order for self-administration of the Hempvona cream and that no medications were to be left in the resident’s room. The Clinical Care Leader stated the process for self-administering medications was not followed because the resident was not assessed, no physician’s order was obtained for self-administration, and the medications were not secured. The DON also confirmed there was no self-administration assessment or order for the creams to be stored and administered in the room, and the Hempvona cream was removed from the room.
Failure to assess residents for self-administration of medications
Penalty
Summary
The facility failed to assess whether two residents were clinically appropriate to self-administer medications. The facility policy required the Interdisciplinary Team to determine which medications could be safely self-administered and to assess the resident’s physical capacity, cognitive status, and ability to store medications securely, with the results documented in a Self Administration of Medication Assessment. For one resident, the clinical record showed diagnoses including paraplegia, Parkinson’s disease, and chronic pain syndrome, and the MDS indicated intact cognition but dependence on staff for activities of daily living. During observation, a tube of ketoconazole cream and a bottle of Derma-Smoothe/fluocinolone scalp oil were found unsecured on the bedside table, and the resident stated he self-administered both medications as needed; the DON confirmed the resident had not been assessed for self-administration as required by policy. For the second resident, the clinical record showed diagnoses including dementia, hallucinations, mild cognitive impairment, atrial fibrillation, and hypertension. Although the MDS recorded intact cognition, the resident was observed taking five scheduled morning medications in his room without a nurse present, and the resident stated he was taking his medications. A physician order stated the resident may not administer his own medications, and there was no evidence that the Interdisciplinary Team had assessed him for self-administration. The LPN confirmed she left the medications at the bedside and left the room, the nurse unit manager confirmed there was no order allowing self-administration, and the DON confirmed the resident had not been assessed per facility policy.
Failure to Assess Clinical Appropriateness for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure self-administration of medications was clinically appropriate for one resident. The resident was admitted with diagnoses including acute chronic diastolic congestive heart failure, acute pulmonary edema, morbid obesity, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, fibromyalgia, and obstructive sleep apnea. The resident’s MDS assessment showed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was observed with a pill left in a medication cup on the bedside table, and later another pill was observed in a medicine cup sitting on the bedside. During the first observation, the resident said she had not noticed the pill until it was pointed out and stated nurses usually left her medications on the bedside table when she was asleep. She recognized the pill as one she took around 11:00 a.m. but could not remember the name of the medication. During the second observation, the resident said she did not see the nurse leave the medicine at her bedside, might have been asleep, and did not take the pill because she was not sure what it was and wanted to ask the nurse before taking it; however, she took the pill before the nurse arrived. Record review showed the resident’s care plan did not include a focus for self-administration of medications. The self-administration assessment dated 1/7/26 approved the resident to self-administer only fluticasone propionate nasal spray and cough drops, with the medications kept at bedside and administered unsupervised. The July 2026 CPO did not show a physician order allowing the resident to self-administer any prescribed medication, yet a pill medication was left at the resident’s bedside. An LPN stated he could not find an order permitting the resident to self-administer her own medication and noted the assessment only documented nasal spray and cough drops. The corporate nurse consultant and DON stated that if a resident requested to self-administer medication, an assessment was performed and, if competent, a physician order would be obtained; they also stated residents approved to keep medications at bedside were given a locked box or sometimes had medications kept in the medication cart until requested.
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