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

A deficiency occurred when a resident with multiple diagnoses, including embolism of the deep veins, malignant neoplasm of the breast, diabetes mellitus, and diabetic neuropathy, was permitted to self-administer Voltaren gel without a documented assessment of her ability to do so safely. The resident had a physician's order allowing unsupervised self-administration of the medication and kept the Voltaren gel at her bedside, applying it as needed. Despite this, her electronic medical record did not contain an assessment for self-administration of medications, and her care plan lacked direction regarding self-administration of Voltaren. Interviews with the resident and facility staff confirmed that no assessment had been completed prior to the resident self-administering the medication. The facility's policy required clinicians to assess and document a patient's ability to self-administer medications, provide education, and record pertinent observations, but these steps were not followed in this case. This failure was identified during a survey, and staff acknowledged the oversight when questioned.