A resident with mild cognitive impairment, multiple medical diagnoses, and a physician order for scheduled DuoNeb nebulizer treatments was repeatedly observed using the nebulizer without staff present, including times when the mask lay on the bed or floor while the machine was running or was held far from the mouth. The care plan documented impaired cognition and the need for supervision and task segmentation, and an intervention to administer treatments as ordered, yet there was no documented self-medication assessment, no care plan direction for self-administration, and no physician order authorizing self-administration, contrary to facility policy requiring an IDT assessment and documentation before allowing self-administration of medications.
Medications Left at Bedside Without Order: A resident with intact cognition and orders for an inhaler and nasal sprays had those medications left in a bag at bedside during observation, even though there was no order allowing bedside storage or self-administration. Staff confirmed the resident wanted the meds left with her and that they were left there because she would scream if she did not get her way; an LPN and the ADON both acknowledged there was no order for bedside medication storage.
Failure to assess self-administration of medication: A resident with moderate cognitive impairment and diagnoses including renal failure, hip fracture, and COPD had an Albuterol rescue inhaler kept at the bedside and later in her pocket, but the facility had not completed the required self-administration evaluation, obtained an approving order, or documented the arrangement in the care plan. Staff confirmed the resident was not approved to self-administer any medications at the time of review.
A resident was observed in the activity room taking multiple tablets with applesauce while no staff were present, even though the chart had no assessment or order allowing self-administration. The facility policy required observation of medication consumption, and the DON stated the resident should have been supervised because she cannot take her pills without assistance.
A resident with intact cognition and multiple chronic conditions, including A-fib, diabetes, and HTN, was care planned as resistive to care and known to refuse medications, but was not care planned or ordered to self-administer meds. The MAR directed staff to administer three mid-morning pills, and facility policy allowed self-administration only with physician and IDT determination. A CMA placed the medications at the bedside, briefly conversed with the resident, and left the room without administering or confirming ingestion, leaving the meds unattended. The DON and CMAs reported that residents are not permitted to keep meds in their rooms and that staff are expected to remain with residents during administration, while the resident reported that staff periodically leave medications in the room. Facility policy required safe administration as prescribed and restricted self-administration to residents formally assessed and approved to do so.
An RN placed noon meds in front of multiple residents and left before confirming they were taken, allowing residents with cognitive or safety deficits to self-administer without orders to do so. Records showed the residents had diagnoses such as HF, HTN, DM, dementia or cognitive impairment, and care plans required staff to administer meds as ordered. Staff, including an LPN, RN, and DON, stated residents should not take meds unobserved unless they have a self-administration order.
A resident with COPD, heart failure, and diabetes was observed self-administering a nebulizer treatment after stating he had already added medication from a vial kept in his pocket. Although the resident had intact cognition, the record lacked documentation of an assessment showing it was clinically appropriate and safe for him to self-administer the medication, and the care plan directed staff to administer medications as ordered.
A resident with diabetes, paraplegia, and spina bifida was allowed to self-administer insulin without a documented assessment of safety or competency, as required by facility policy. The resident independently injected insulin under RN supervision, but the care plan and medical record lacked evidence of an interdisciplinary team assessment or documentation supporting the decision to permit self-administration.
A resident with diabetes, hypertension, and Parkinson's disease was allowed to self-administer insulin without thorough documentation of an assessment to determine clinical appropriateness. Despite staff facilitating the resident's self-administration and a note indicating he managed the task, the care plan and records lacked comprehensive assessment details as required by facility policy.
The facility did not complete required self-medication administration assessments for two residents—one with diabetes and another with severe allergies and an order for an EpiPen at bedside. Both residents were either observed with medications at bedside or had orders to self-administer, but there was no documented interdisciplinary assessment as required by facility policy. Staff were also unaware of one resident's allergies and the location of emergency medication.
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