F0554

D

Failure to Obtain Physician Orders Before Allowing Self-Administration of Medications

Parkston, South Dakota Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain and verify physician orders for self-administration of medications before leaving medications with residents at the dining table. Surveyors observed on multiple occasions that RNs left cups containing multiple oral medications with two residents during breakfast in the dining room and then left the area, allowing the residents to take the medications on their own. One observation showed a resident dropping a yellow pill on the floor and notifying a surveyor, who then alerted the RN. On another occasion, an RN instructed a resident that if he did not want his MiraLAX, he should leave it on the table, and the resident delayed taking his medications while engaging in other activities such as changing the TV channel.

Review of the electronic medical records and interviews with nursing staff revealed that neither of the two residents had a physician’s order authorizing self-administration of their routine oral medications, despite one resident having an order only to self-administer Kenalog paste for oral sores and the other having an order only to self-administer/self-consume nebulizer treatments after setup. The facility’s policies on medication management and self-administration required that residents be assessed for clinical appropriateness and that a physician’s order for self-administration be obtained and entered into the EHR before allowing self-administration. Staff interviews confirmed that a self-administration assessment should be completed first, followed by obtaining a physician’s order, and that nurses should verify the presence of such an order before leaving medications with a resident, which did not occur for these two residents.