Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly assess and document the ability of two residents to self-administer medications, as required by its own Self-Administration Protocol. For one resident with severe cognitive impairment and a history of IV therapy, IV fluids and heparin lock flush solution were found at the bedside without any physician's order, care plan documentation, or assessment for self-administration. Staff confirmed that the resident was not currently on IV therapy and had not been assessed for self-administration, and the presence of the IV bag at the bedside was not appropriate. For another resident with little to no cognitive impairment, multiple medications, including a nasal spray and a topical gel, were found at the bedside. There was no documentation in the care plan or clinical record of an assessment for self-administration of medication, and one of the medications present was not prescribed in the physician's orders. Staff interviews confirmed that the resident self-administered medication without a formal assessment and that staff were unaware of the facility's procedure for self-administration. The Director of Nursing confirmed that no residents had been assessed for self-administration of medication, despite facility policy requiring such assessments.