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 facility failed to ensure that residents approved for self-medication had completed self-administration assessments, physician orders, and proper lockbox storage. Surveyors found one resident with dementia had pills left on a nightstand without an assessment or order, and another resident had multiple meds and powders on the bedside table even though only one item was authorized for self-administration and policy required locked storage.
Failure to assess a resident for self-administration of meds. A resident with intact cognition and hypothyroidism was left unsupervised with a scheduled levothyroxine dose by an LPN, even though there was no physician order or care plan indication allowing self-administration and no self-administration safety assessment completed. Staff also found a bottle brought in by the family labeled as Refresh Eye Drops that actually contained baby oil.
A resident with intact cognition and orders for Ventolin via nebulizer was observed self-administering her treatment without staff present. The EMR had no completed medication self-administration assessment and no physician order authorizing self-administration, and an RN stated the resident was okay to give it to herself despite the facility policy requiring both an assessment and provider order.
A resident with intact cognition was allowed to keep bedtime meds on her nightstand under a physician order, but no self-administration safety screen was documented for the oral bedtime meds, which included a thyroid med, a blood thinner, a BP med, and Tramadol. RN, DON, and admin review confirmed that the resident's bedtime oral meds had not been assessed for safe self-administration and that opioids were not allowed for self-administration at the facility.
A facility failed to ensure that residents using bedside meds had been assessed for safe self-administration and had physician orders authorizing it. Surveyors observed a resident with COPD independently using nebulizer treatments after staff set them up, another resident with COPD and legal blindness using a nebulizer without monitoring, and two other residents with mouthwash and topical cream at bedside. Records showed intact cognition for several residents, but no valid self-administration assessments or physician orders supporting bedside use.
A RN handed a resident a Trelegy Ellipta inhaler so the resident could self-administer it, even though there was no provider order for self-administration of that specific medication and no self-administration assessment for the inhaler. The DON's assessment covered the resident's nebulizer use only, and both the RN and DON confirmed the resident was not assessed or ordered to self-administer the inhaler, despite the facility policy requiring competency determination and a provider order for each medication.
Failure to assess a resident for safe self-administration of nebulizer medication. A resident was found alone in his room with a nebulizer treatment running, but the mask was not properly positioned over his nose and mouth. The CMA said she was unsure whether the treatment could be given without supervision and could not find a physician order for self-administration. The resident was nonverbal, had quadriplegia, cognitive communication deficit, traumatic brain injury-related diagnoses, and required extensive assistance with cares.
A facility failed to ensure proper assessment and physician authorization for medication self-administration for three residents. One resident with severe cognitive impairment was set up for a nebulizer treatment and left for staff to return later, another resident with intact cognition improperly self-administered an inhaler without assessment or order, and a third resident with moderate cognitive impairment had Prostat left at the bedside without an assessment or order supporting bedside placement.
Surveyors found that staff left cups containing multiple oral medications with two residents at the breakfast table and then left the area, allowing the residents to take the medications on their own, including one instance where a pill was dropped on the floor. Review of the EMR and staff interviews showed there were no physician orders authorizing these residents to self-administer their routine oral medications, even though each only had limited orders for self-administration of specific treatments (Kenalog paste and nebulizer therapy). Facility policies required an assessment and a physician order for self-administration to be in place before residents could self-administer medications, but this process was not followed in these cases.
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