Failure to Assess Resident Before Allowing Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined a resident was safe to self-administer medications before allowing this practice. Facility policy titled "Medication- Self Administration-Assessment, Review, Care Planning, Documentation" (revised April 2022) requires a uniform process for assessing residents for self-administration, care planning, and documentation. Resident 10, who had diagnoses including Type II Diabetes Mellitus and Congestive Heart Failure, was observed on February 2, 2026, with a medication cup containing multiple medications placed on the bedside table. During an immediate interview, the resident stated that the Licensed Practical Nurse (Employee 10) leaves the medications there for him to take at his leisure and with his drink of choice. In a subsequent interview, Employee 10 acknowledged that the resident had not been assessed to self-administer medications. The Nursing Home Administrator also confirmed that the medications should not have been left at the bedside and that the resident had not been assessed by the facility for self-administration of medications, indicating noncompliance with the facility’s own policy and 28 Pa. Code 211.12(d)(1)(2)(5) regarding nursing services.
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