Failure to Assess and Document Self-Administration of Albuterol
Summary
The facility failed to ensure that Resident 23 was assessed before being permitted to self-administer albuterol inhaler medication and failed to ensure accurate documentation of the resident’s self-administration. Resident 23 was admitted with diagnoses including COPD, asthma, and chronic respiratory failure. The MDS dated 4/16/2026 indicated intact cognition and use of a manual wheelchair with supervision or touching assistance needed for transfers. The physician order for albuterol HFA inhalation aerosol solution, entered with a start date of 4/17/2026, instructed two puffs every four hours as needed for asthma, shortness of breath, or wheezing and allowed the resident to self-administer and keep the inhaler at bedside. During observation on 5/17/2026, Resident 23 was seen on the outside patio removing the inhaler from a jacket pocket and self-administering two doses. In interview, the resident stated the inhaler was kept on hand for quick use, that staff had not been asking when it was used prior to 5/17/2026, and that the resident used it as often and whenever desired despite the order stating every four hours as needed. The MAR for May 2026 did not show any use of the inhaler. The SAM dated 5/17/2026 indicated the resident could safely self-administer medication, and the DON stated the required assessment had not been completed until 5/17/2026. The facility policy stated a resident may only self-administer medications after the interdisciplinary team determines which medications may be self-administered safely, and that bedside medication self-administration is to be recorded on the MAR.
Penalty
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Medications were left at a resident’s bedside without a completed SAM assessment or physician order. The resident had moderate cognitive impairment on admission and diagnoses including UTI and COPD, but the EMR lacked a SAM assessment, bedside medication orders, and a related care plan. Surveyors observed nystatin cream, refresh eye drops, and later diclofenac cream in a basin in the resident’s room, while an LPN, RN, and DON confirmed the assessment was expected before medications were left in the room.
The facility failed to complete SAM assessments and obtain provider orders before leaving medications at the bedside for two cognitively intact residents. Both residents had SAM inquiry forms indicating they did not want to self-administer medications, yet labeled antifungal medications were observed in their rooms and their orders lacked SAM authorization. An LPN stated bedside medications require a doctor’s order and assessment, and the DON confirmed neither resident had a SAM assessment.
Medications Left at Bedside Without Self-Administration Assessment: A resident with a BIMS of 15 and diagnoses including polyneuropathy and vitreous degeneration had medications left in a cup at the bedside on two observations. The resident's assessment stated she did not desire to self-administer medications, and there was no physician order or care plan documentation for self-administration. An MT said she left the medications for the resident to take, while an RN said the resident was supposed to be watched but preferred to take meds on her own.
Failure to Assess and Secure Self-Administered Medications: A resident with COPD and moderately impaired cognition was observed receiving a nebulizer treatment without a self-administration assessment or physician order, and the RN left her alone while the treatment continued. Another resident with intact cognition self-administered a Symbicort inhaler and fluticasone nasal spray, but staff left both medications on her bedside table for hours and overnight despite no order to keep them at bedside and an order to return them to the med cart after use.
A resident with dental caries, hemiplegia, visual loss, cognitive communication deficit, and a history of TBI was found with chlorhexidine mouthwash at bedside, even though the facility had no documented IDT assessment or care plan focus for self-administration. The MAR showed repeated mouthwash orders that allowed bedside storage, but the MDS Nurse found no meeting notes showing the request was discussed, and the DON confirmed no IDT discussion occurred regarding self-administration.
Failure to Assess Self-Administration of Medications: A resident with HF, HTN, and DM had fluticasone nasal spray and an albuterol inhaler kept at bedside, but the clinical record lacked an assessment or MD order for self-administration. The resident said they kept the meds nearby so they would not have to wait for nursing staff, and the UM confirmed the facility had not determined whether self-administration was safe or clinically appropriate.
Medications Left at Bedside Without SAM Assessment or Order
Penalty
Summary
The facility failed to complete a Self-Administration of Medication (SAM) assessment and obtain a physician order before medications were left at the bedside for one resident. The resident had a Brief Interview for Mental Health on admission that indicated moderate cognitive impairment and had diagnoses of urinary tract infection and chronic obstructive pulmonary disease. The electronic medical record did not contain a SAM assessment, orders to keep medications at bedside, or a care plan related to the resident’s ability to self-administer medications. Surveyors observed nystatin cream and refresh eye drops in a pink wash basin on the counter in the resident’s room on multiple occasions, and diclofenac cream was also later observed there. During interview, an LPN stated that a SAM assessment and orders were needed before medications could be left at bedside and that the assessment was usually completed about a week after admission. An RN stated the same, and the DON stated the expectation was that the SAM assessment would be completed prior to medications being left at bedside. Facility policy stated a SAM assessment would be performed at admission and orders obtained, if approved, prior to medications being left in the room, and the care plan would be updated to add the SAM assessment.
Failure to Complete SAM Assessments and Obtain Orders Before Leaving Medications at Bedside
Penalty
Summary
The facility failed to ensure a self-administration of medication (SAM) assessment was completed and a provider order was obtained before medications were left at the bedside for 2 residents reviewed for medication administration. One resident was cognitively intact with diagnoses including atrial fibrillation, high blood pressure, and renal insufficiency. That resident’s SAM inquiry form, signed by the resident, indicated the resident did not want to self-administer medications independently or after set-up by facility staff, yet a bottle of Nystatin powder with the resident’s pharmacy label was observed on the dresser and the resident’s orders lacked a SAM order. A second resident was also cognitively intact with diagnoses including heart failure, high blood pressure, ESRD, and diabetes. The resident’s SAM inquiry form, signed by the resident, likewise indicated the resident did not want to self-administer medications independently or after set-up by facility staff, but a bottle of antifungal powder with the resident’s pharmacy label was observed on the bedside table and the resident’s orders lacked a SAM order. An LPN stated medications could be left at the bedside only if there was a doctor’s order and the resident had been assessed as safe to self-administer. The DON confirmed both residents did not have a SAM assessment and stated her expectation that residents be assessed and have a physician’s order before SAM was put in place or medications were left at bedside.
Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that all residents were clinically appropriate to self-administer medications for one resident observed with medications at bedside. The resident had diagnoses including polyneuropathy and vitreous degeneration of unspecified eye, and the quarterly MDS showed a BIMS score of 15, indicating the resident was cognitively intact. However, the resident's Quarterly/Annual/Significant Change Assessment dated 5/27/26 stated that the resident did not desire to self-administer her own medications, and there was no physician order for self-administration in the MAR or information in the comprehensive care plan addressing self-administration. Surveyors observed two medications in a cup on the resident's bedside table on one occasion and all of the resident's morning medications in a cup on the bedside table on another occasion. The resident stated the nurse brought the medication in but she had not taken them yet. A medication tech stated she had left the medications for the resident to take and believed the resident was able to self-administer medications, while an RN stated the resident was supposed to be watched while taking medications but preferred to take them on her own. The DON confirmed that the facility's process required a self-administration assessment, a physician's order, and care plan documentation, and stated the resident should not have medications left at bedside.
Failure to Assess and Properly Store Self-Administered Medications
Penalty
Summary
The facility failed to ensure residents were assessed for the ability to safely self-administer medications and had the required physician orders for self-administration and bedside storage. One resident with pneumonia and COPD, and a BIMS score of 9 indicating moderately impaired cognition, was observed in her room waiting for a scheduled DuoNeb nebulizer treatment. She stated she had not refused the treatment and believed the RN was late. The resident’s record showed an order for DuoNeb by nebulizer three times daily, but there was no self-administration assessment and no physician order authorizing her to self-administer the nebulizer treatment. During the observation, the resident was left alone while the nebulizer treatment was running. She fidgeted with the mouthpiece, repeatedly removed it from her mouth and replaced it, then fell asleep with the mouthpiece falling away from her mouth while the treatment continued. The RN walked past the room multiple times without checking on her. The RN later stated she knew the resident had not been assessed for self-administration and was not aware she should have remained with the resident during the treatment. The DON acknowledged the resident did not have a self-administration assessment or physician order to self-administer the nebulizer treatment. A second resident with intact cognition, COPD, and allergic rhinitis was observed with a Symbicort inhaler and fluticasone nasal spray on her bedside table. She stated she used them when she woke up and sometimes forgot to tell staff, leaving the medications on the bedside table for hours and at times overnight. Her record showed orders for both medications and a self-administration evaluation indicating she could self-administer them, but the evaluation also indicated there was no order to keep medications at bedside and that storage location was the medication cart. Staff stated they placed the medications at the bedside because the resident liked to sleep in, and the DON acknowledged the medications were left in the room for hours and overnight despite no physician order to store them there and an order stating they were to be returned to the medication cart after use.
Failure to Assess Self-Administration of Mouthwash
Penalty
Summary
The facility failed to properly assess a resident for the appropriateness of self-administration of prescription chlorhexidine mouthwash. The resident had diagnoses including dental caries, right-sided hemiplegia, visual loss in the right eye, cognitive communication deficit, and a personal history of traumatic brain injury. Her quarterly MDS showed a BIMS score of 15 out of 15, and her care plan addressed dental pain and antibiotic use, but it did not include any focus, goal, or intervention related to self-administration of medications or chlorhexidine mouthwash. Review of the resident’s medication records showed three separate chlorhexidine gluconate 0.12% mouthwash orders, including orders that stated the mouthwash could be kept at bedside. During observation, a bottle of chlorhexidine mouthwash was found on the resident’s bedside table while the resident was not in the building, and no lock box or lock on the bedside drawer was observed. An LPN stated the resident wanted the mouthwash at bedside so she could use it after meals and said the resident had no problems self-administering it, but also stated he was unsure why the mouthwash remained at bedside after the order ended. The DON stated the request to self-administer the mouthwash would have been discussed in the morning meeting and added to the care plan, and the Administrator stated that residents who self-administer medications should have an assessment and physician’s order. However, the MDS Nurse found no notes showing that the resident’s request to self-administer the mouthwash had been discussed, and the DON later confirmed that no IDT meeting or discussion had occurred regarding the resident self-administering the prescribed chlorhexidine mouthwash.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to determine whether it was safe for one resident to self-administer medications. Review of the facility policy on self-administration of medications indicated that the facility should assess whether self-administration is safe and clinically appropriate based on the resident’s functionality and health condition, and that orders for self-administration should list the specific medications the resident may self-administer. The resident’s clinical record did not include an assessment or physician order to self-administer medications. The resident was admitted to the facility and had diagnoses of heart failure, high blood pressure, and diabetes. During an observation, the resident was sitting in bed with a bedside table pulled close, and a container of fluticasone nasal spray and an albuterol inhaler were on the table. Neither medication was stored in a bag, and neither was labeled with the date opened. The resident stated they preferred to keep the medications at bedside so they would not have to wait for nursing staff when needed. The Unit Manager confirmed the record lacked an assessment or physician order and that the facility failed to determine whether self-administration was safe for the resident.
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