Missing physician order for self-administered bedside Melatonin
Summary
The facility failed to ensure that a resident who was keeping Melatonin 5 mg at the bedside had a physician order for the medication and a physician order to self-administer medications. The facility’s policy required an interdisciplinary assessment and a prescriber’s order before a resident could self-administer medications, and it also required documentation of the determination in the medical record and care plan. In this case, the resident’s care plan documented that the resident was able to safely administer medications, and a self-administration assessment completed on 10/27/25 approved the resident to self-administer and keep medications at bedside, but the resident’s physician orders did not include an order to self-administer and the surveyor could not locate an order for Melatonin. The resident was admitted with multiple diagnoses including Multiple Sclerosis, Spastic Hemiplegia affecting the right dominant side, Neuromuscular Dysfunction of Bladder, Irritable Bowel Syndrome with Diarrhea, Type 2 Diabetes Mellitus, COPD, Insomnia, and Major Depressive Disorder. The Quarterly MDS documented a BIMS score of 15, indicating the resident was cognitively intact for daily decision making. The MDS also documented significant physical assistance needs, including wheelchair use, range of motion impairment, substantial or maximum assistance with showers, upper dressing, and mobility, dependence for lower dressing and transfers, and an indwelling catheter. Survey observations showed a bottle of Melatonin 5 mg gummies on the resident’s overbed table on multiple occasions, and the resident stated taking 2 gummies every night. The resident also stated not keeping track of taking the Melatonin on a nightly basis. The DON confirmed the resident should have a physician order for the Melatonin and for self-administration, but later stated the resident would not give up the Melatonin and the physician would not give the order due to conflicts. The surveyor noted there was no documentation in the EMR that the physician had been contacted about the Melatonin at bedside, and the Melatonin remained at the resident’s bedside throughout the observations.
Penalty
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A cognitively intact resident with arthritis was found keeping OTC Tylenol and a decongestant nasal spray at the bedside without any documented assessment for self-administration. The resident said a family member brought in the meds and that she used them on her own, while the RN stated no residents on the unit were assessed to self-administer meds and the DON confirmed the resident should have been assessed if she wanted to keep and use medications in her room.
A cognitively intact resident with compression fracture of the spine, epilepsy, and GERD had PRN Tums ordered, but the record did not show an assessment for self-administration before the medication was kept at the bedside. Nursing documentation and the care plan stated the resident did not choose to self-administer medications and that staff were to administer meds as ordered, yet a container of Tums was observed on the bedside table and RN-B confirmed no self-administration assessment had been completed. The DON stated the facility process required physician notification, a nursing assessment, physician authorization, and care plan interventions before bedside medication storage.
A resident kept topical meds in a drawer and had written instructions posted at the bedside, but the chart had no self-administration assessment and no MD order allowing self-administration. The resident was cognitively intact and was observed scratching both arms, while RN and the DON stated the resident was not permitted to keep meds at the bedside and that family had continued bringing in meds despite prior education.
Failure to complete self-medication assessments for two residents: one resident with depression and moderate cognitive impairment had a medication cup left at bedside and did not know what the pills were, and the DNS confirmed no self-medication assessment was in the chart. Another resident with diabetes was self-administering insulin and choosing the dose, but the record lacked a self-medication assessment, provider order, and care plan authorizing self-administration.
A resident who was cognitively intact and receiving multiple scheduled meds had no documented self-administration assessment and no physician order for self-administration. Staff left a medication cup unattended at the bedside, the resident said nurses left the meds there so she could spread them out, and an LPN and the DON both confirmed the meds were being left at bedside without the required assessment or order.
A resident with multiple diagnoses, including diabetes and hypertensive heart failure, had clobetasol ointment kept at bedside and was applying it without a completed SAM assessment or provider order. The resident said the facility lost the cream, the husband brought in a replacement from home, and the cream was observed on the nightstand. Staff and the DON stated a SAM assessment and physician order were required before a resident could self-administer and keep medication at bedside, and the facility policy required the same.
Failure to Assess Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to assess whether a cognitively intact resident with arthritis could safely self-administer medications kept at the bedside. Resident #46 was admitted with a diagnosis of arthritis, and the admission MDS dated [DATE] indicated the resident was cognitively intact. Review of the medical record showed no documentation that Resident #46 had been assessed for the ability to self-administer medications, even though a physician order dated 03/17/26 allowed Tylenol 325 mg, 2 tablets by mouth every 6 hours as needed for pain. On 06/08/26, Resident #46 was observed with a bottle of OTC Tylenol 325 mg and a bottle of decongestant nasal spray on the bedside table. The resident stated she used the Tylenol before therapy for pain and used the nasal spray daily for congestion, and said the medications had been brought in by a family member and had been at the bedside for a couple of weeks. Subsequent observations on 06/09/26 and 06/10/26 again found both bottles on the bedside table. Nurse #1 stated she was not aware of any medication at the bedside and that no residents on the unit were assessed to self-administer medications. The DON stated no resident was allowed to keep home medications in the room and that Resident #46 should have been assessed if she wanted to keep and administer medications in her room. The Administrator stated nurses were expected to notice bedside medications and remove them immediately.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident’s ability to self-administer medications before allowing medication to be kept at the bedside. The resident, R126, was cognitively intact on the admission MDS and had diagnoses including compression fracture of the spine with routine healing, epilepsy, and GERD. Physician orders dated 5/28/26 included Calcium Carbonate (Tums) 500 mg, two tablets by mouth every four hours as needed for heartburn or upset stomach, but the orders did not indicate that R126 was able to self-administer medication. The comprehensive nursing data collection dated 5/28/26 stated the resident had not brought medications on admission and did not choose to self-administer medications, and the care plan dated 6/1/26 also stated the resident chose not to self-administer medications, with interventions directing staff to administer medications as ordered. Despite this documentation, the medical record lacked evidence that R126 had been assessed for self-administration of medications. During observation on 6/8/26, a container of Tums was seen on R126’s bedside table, and the resident stated family had brought the medication to the facility so it would be available because he had not received it when requested during a previous hospitalization. RN-B confirmed the Tums were on the bedside table and stated no self-administration assessment had been completed, adding that an order and assessment were required if a resident was to self-administer medications. The DON stated the facility’s process for self-administration required physician notification, a nursing assessment, physician authorization, and care plan interventions, and the facility policy directed staff to assess the resident’s ability to safely self-administer medications before allowing medications to be kept at the bedside.
Failure to Assess and Order Self-Administration of Topical Medications
Penalty
Summary
The facility failed to ensure a resident was assessed for self-administration of medications and did not have a physician's order permitting self-administration of medications. Resident 43 was cognitively intact per the admission MDS dated 4/28/26. During an interview, the resident stated she kept two ointments in a drawer in her room, and a tube of tacrolimus ointment was observed there. The resident also reported using triamcinolone ointment, which had gone missing. A paper with instructions for both ointments was posted on the chest of drawers, and the resident was observed scratching both arms during the interview. Record review showed physician's orders for tacrolimus ointment 0.1% every 12 hours as needed and triamcinolone acetonide cream 0.1% every 12 hours as needed, but there was no self-administration assessment and no physician's order for the resident to self-administer her own medications. RN 2 stated the resident was not permitted to keep medications at the bedside, and the tacrolimus tube found in the drawer had a worn-off pharmacy label and blue tape marked "face." The DON stated the family had previously brought medications into the facility and continued to do so even after being educated that nursing staff needed to be notified of any new skin issues or itching so the resident could be properly assessed.
Failure to Complete Self-Medication Assessments
Penalty
Summary
The facility failed to timely complete self-medication assessments for two residents who were receiving medications in ways that required evaluation and documentation. One resident with depression and moderate cognitive impairment was observed sitting in bed with a medication cup containing four pills on the bedside table, and the resident stated the nurse had left the medication for him to take. The resident did not know what the medications were. The LPN who was interviewed was unsure whether a self-medication assessment had been completed, and the DNS later confirmed that no self-medication assessment was in the resident’s clinical record. A second resident with diabetes mellitus was receiving lispro insulin by sliding scale, scheduled lispro insulin three times daily, and lantus insulin with breakfast. The May 2026 MAR/TAR showed the resident self-administered insulin on multiple dates, and the DNS stated the resident chose the dosage amount and self-administered her insulin medications, with the medical provider aware. However, the clinical record did not include a self-medication assessment, medical provider orders authorizing self-medication, or a care plan indicating the resident was able to self-medicate her insulin. The facility policy provided by the DNS stated residents requesting to self-medicate or with self-medication in the plan of care are to be assessed and the assessment documented in the EHR.
Unassessed Medication Self-Administration
Penalty
Summary
The facility failed to ensure medication self-administration evaluations were completed for a resident who was cognitively intact and receiving multiple scheduled medications. The resident had diagnoses including hypocalcemia, type II diabetes mellitus, anxiety disorder, depression, hypothyroidism, adjustment disorder with mixed anxiety and depressed mood, paranoid personality disorder, malignant neoplasm of the thyroid gland, and mild neurocognitive disorder due to a known physiological condition without behavioral disturbance. The medical record contained no evidence that a self-administration assessment had been completed or that a physician’s order was in place for the resident to self-administer medications. Review of the MAR showed the resident received numerous morning medications, including diabetes, thyroid, psychiatric, vitamin, and other medications. During observation, a medication cup approximately half full of medications was found on the resident’s bedside table with no nursing staff present in the room. The resident stated the nurses left the medications at bedside because she liked to spread them out, and an LPN confirmed the medications were being left unattended at the bedside. The DON also verified the resident had not been assessed to self-administer medications and did not have a physician’s order for self-administration, while stating the resident would be appropriate to self-administer medication.
Failure to Complete SAM Assessment Before Bedside Medication Use
Penalty
Summary
The facility failed to ensure a self-administration of medications (SAM) assessment was completed before allowing a resident to keep and apply clobetasol propionate external ointment at bedside. The resident’s MDS indicated the resident was cognitively intact but required substantial to maximal assistance with toileting hygiene, upper and lower body dressing, bed mobility, and transfers, and moderate assistance with oral and personal hygiene; the resident was also dependent on staff for bathing. The resident had diagnoses including pneumonia, acute respiratory failure with hypoxia, hypertensive heart failure, diabetes, anxiety disorder, and chronic low back pain. Physician orders included clobetasol ointment for lichen planus, and the MAR showed the medication was administered by staff as ordered. The nursing admission assessment documented the self-administration question as not applicable. During interview, the resident stated the staff had lost the medicated cream and that the resident’s husband brought in the clobetasol from home; the cream was observed on top of the nightstand in the resident’s room. The resident stated the cream was being applied every day and as needed. Staff interviews showed RN-E stated residents could self-administer medications only if alert and oriented, after a SAM assessment, and with a doctor’s order. RN-H stated she was not aware the resident had the cream in the room, retrieved it from the room, and stated a SAM assessment and provider order were needed for self-administration and that the medication would need to be reordered from the pharmacy. RN-F and the DON both stated a SAM assessment, provider order, and proper procedure were required before medication could be left at bedside. The facility policy also required a SAM assessment, physician order, and bedside storage in a locked box.
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