Failure to Secure Medications and Assess Residents for Self-Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were securely stored and that residents did not self-administer medications without appropriate physician orders and assessments. One resident with Type 2 Diabetes Mellitus had active orders for Novolog insulin and Ozempic, but no physician order permitting self-administration or in-room medication storage. Surveyors observed this resident seated in bed with opened and partially used Novolog and Ozempic pens on the bedside table on two consecutive days. The resident stated he kept the medications at his bedside and administered them himself because he felt his medications were sometimes given late. The DON confirmed that residents are not permitted to have medications in their rooms or self-administer unless there is a physician order and an assessment confirming it is safe, and the Administrator confirmed that no self-administration assessment had been completed for this resident. A second resident had an order for Breo Ellipta inhalation aerosol powder, to be taken once daily with instructions to rinse the mouth and spit after use, but there was no order for self-administration or in-room storage. Surveyors observed this resident sitting on the side of the bed with the Breo inhaler on the bedside table; the resident reported having just used it and was unsure if anything needed to be done after taking the medication. The medical record contained no self-administration assessments, and the resident’s care plan did not address any desire or attempts to self-administer medications. An LPN stated that residents who self-administer must be assessed and have an order. Facility policies on administering medications and self-administration specified that medications may only be self-administered upon assessment and physician order, and that bedside storage is not permitted unless the resident has been assessed and found safe to do so, which had not occurred for these residents.
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