Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A deficiency was identified when a resident was observed to have a bottle of Refresh tears and Fluticasone nasal spray on their bedside table, which the resident reported self-administering 1-2 times daily since admission about a month prior. Despite these observations, there was no documentation in the resident's medical record of an assessment to determine if self-administration of these medications was clinically appropriate. Additionally, there were no physician orders for either medication. Further review of facility policy revealed that residents requesting to self-administer medications must undergo a self-administration evaluation by a licensed nurse to assess safety and understanding, and a healthcare provider's order is required. The policy also specifies that residents should be instructed on safe storage of medications, including the use of a locked box. Staff confirmed that these procedures were not followed for this resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.