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's interdisciplinary team (IDT) failed to determine if it was clinically appropriate for two residents to self-administer medications and keep medications at bedside. For one resident, a medication technician stated there was an order for self-administration, but the care plan did not reflect this, and there was no documented assessment or care plan intervention for self-administration. The resident's clinical record lacked evidence of a self-administration assessment, a physician order for self-administration, and documentation in the care plan. The Long Term Care Unit Manager confirmed these findings during a review of the resident's record. For another resident, a bottle of eye drops was observed at bedside, but the clinical record did not contain an order for self-administration, an IDT assessment, or care plan documentation for self-administration. The medication administration record also lacked evidence of administration of the eye drops. The resident reported self-administering the drops, and an LPN confirmed that the record lacked the required order and assessment for self-administration. These findings were discussed with facility staff and confirmed through interviews and record review.