Unassessed Medication Self-Administration and Misplaced Medication Cup
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to professional standards and facility policy when a resident was effectively left to self-administer medications without a required assessment. The resident, admitted in 1/2019 with hemiplegia, hemiparesis, and dysphagia, had an admission/readmission data tool dated 8/14/24 indicating he did not want to self-administer medications. A BIMS completed on 2/6/26 showed intact cognition with a score of 14. On 3/4/26 at 8:53 a.m., surveyors observed a medicine cup labeled for bed 18B containing three pills on top of the overbed table of the resident in bed 18C. The resident confirmed he occupied bed 18C, stated he was not sure if the medications were his, and reported that no nursing staff had assessed whether it was safe for him to take medications without supervision. The resident reported he had not requested to self-administer medications or to have medications left at his bedside and that he did not take the medications because he had difficulty taking them without assistance. During interviews, LN A verified the medicine cup labeled 18B with three pills was on the overbed table of the resident in 18C and acknowledged uncertainty about what the medications were. LN B stated she was not sure if the resident was safe to self-administer medications and confirmed that facility policy did not allow medications to be left at bedside or residents to self-administer without an assessment by the IDT. The interim DON verified that the admission/readmission data tool indicated the resident did not want to self-administer medications and that there was no assessment indicating it was safe for the resident to do so. The interim DON stated that, in the absence of such an assessment, staff should not allow the resident to self-administer medications and that allowing this could result in accidents such as choking. Facility policies on administering medications and self-administration required that residents may self-administer only if the attending physician and IDT determined it was clinically appropriate and safe.
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