Failure to Supervise Medication Administration and Unauthorized Self-Administration
Penalty
Summary
Surveyors identified a deficiency in medication administration supervision for Resident #4, who had intact cognition with a Brief Interview for Mental Status score of 15 and diagnoses including atrial fibrillation, anxiety, arthritis, depression, diabetes, edema, and hypertension. The resident’s care plan, last revised on 10/20/25, documented that the resident was resistive to cares and had a history of refusing medications if they did not feel the medications were necessary, with interventions directing staff to educate the resident on possible outcomes of noncompliance. The care plan did not document that the resident could self-administer medications. The MAR and current physician orders directed staff to offer two different medications mid-morning for a total of three pills and did not indicate that the resident was allowed to self-administer medications. During an observation, a CMA entered the resident’s room with a small cup containing three pills, placed it on the bedside table in front of the resident, visited briefly, and then left the room without acknowledging or administering the medications, which remained on the bedside table. The DON stated that staff are required to stay with residents when administering medications and should not leave residents alone with medications. CMAs interviewed reported that no residents were independent to keep medications in their rooms and that they would not leave medications with a resident in their room. The resident confirmed that medications were left in their room by staff and reported that this occurred periodically. Facility policy on administering medications stated that medications shall be administered in a safe and timely manner as prescribed, and that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined the resident has the decision-making capacity to do so safely.
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