Failure to Assess and Obtain Order for Resident Self-Administration of Bedside Medication
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, assess, and obtain a physician’s order for a resident to self-administer medication and keep it at the bedside. The facility’s medication administration policy, revised in April 2019, required that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determined they had the decision-making capacity to do so safely. The resident’s admission MDS dated 01/20/2026 showed they were cognitively intact and had a diagnosis of GERD. Surveyor observation on 02/03/2026 at 2:00 PM revealed a stack of medication cups on the resident’s bedside table, with one cup containing three round tablets and another containing one round tablet. The resident identified the tablets as TUMS (calcium carbonate) and stated they took them when needed and that some nurses observed them taking medications and some did not. A subsequent observation on 02/04/2026 at 1:59 PM again showed a medication cup with three round tablets on the bedside table. Review of the resident’s physician orders printed on 02/04/2026 showed an order for calcium carbonate chewable tablets, 1,500 mg by mouth before meals for GERD, but no order authorizing self-administration or keeping the medication at the bedside. During an interview and joint observation on 02/04/2026 at 4:05 PM, an LVN confirmed that residents requesting medications at bedside must be assessed for safe self-administration and acknowledged that this resident did not have such an order and that the medication should not have been at the bedside. In a later interview and record review on 02/06/2026, the charge RN confirmed there was no order permitting self-administration or bedside medications, and the DON stated that staff were expected to complete an evaluation and obtain a physician’s order before allowing a resident to self-administer and keep medications at bedside. The lack of assessment and physician order for this resident’s bedside TUMS constituted the cited deficiency.
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.