Failure to Assess Resident for Self-Administration of Medication
Summary
The facility failed to assess a resident for self-administration of medications prior to allowing the resident to keep medication at their bedside. A resident with a history of nontraumatic intracranial hemorrhage, COPD, and anxiety disorder was admitted and had a BIMS score indicating intact cognition, but required moderate assistance with all activities of daily living. The resident's care plan did not indicate the ability to self-administer medication, and there was no physician order or documented assessment for self-administration in the medical record. Despite this, repeated observations over several days showed the resident kept an albuterol inhaler at their bedside. Interviews revealed that staff were aware of the inhaler at the bedside but had not questioned the resident about it or followed the facility's process for self-administration of medications. The RN was unsure of the process and only removed the medication after being made aware of the issue. The DON confirmed that the facility policy required an assessment and physician order for self-administration, neither of which had been completed for this resident. The facility policy also required self-administration to be reflected in the care plan, which was not done.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple medical conditions was left with an albuterol nebulizer treatment in their room by an LPN, despite not having a physician's order to self-administer medications. Facility policy required such an order and interdisciplinary team approval, which were not obtained.
A resident with COPD and intact cognition was found with a prescribed inhaler left at their bedside without a physician's order or assessment for self-administration. Facility policy required an interdisciplinary assessment and order before allowing self-administration or bedside storage, but these steps were not completed. Staff interviews confirmed the oversight.
A resident with severe vision impairment and multiple diagnoses was allowed to self-administer medications without the required annual reassessment to confirm ongoing safety and capacity, as mandated by facility policy. The initial assessment was not updated, and the interdisciplinary team did not complete the necessary review.
The facility failed to assess two residents for their ability to self-administer medications, as required by policy. One resident self-administered insulin and other medications without an assessment or physician order, while another applied Lidocaine patches and kept Flonase at the bedside without proper documentation or orders. The DON confirmed the lack of assessments and orders for both residents.
A resident with a physician's order to self-medicate was found to have medications stored in an unsecured manner, contrary to facility policy. The resident, with a history of diabetes, hypertension, and schizophrenia, kept medications in a cardboard box next to his bed without a lock. Interviews confirmed the lack of secure storage, violating the facility's policy requiring medications to be locked and accessible only to authorized personnel.
A resident with asthma was found to self-administer an albuterol inhaler without informing nursing staff, and without a proper assessment or documentation. Interviews and observations confirmed the resident's actions and the facility's failure to follow its policy on medication self-administration.
Medication Left Unattended Without Self-Administration Order
Penalty
Summary
The facility failed to ensure that medications were not left unattended in resident rooms, as evidenced by an incident involving a resident with diagnoses of atrial fibrillation, malignant prostate cancer, and pneumonia. The resident, who had intact cognition and required moderate staff assistance with ADLs, did not have a physician's order to self-administer medications. During observation, an LPN placed an ampule of albuterol into the resident's nebulizer and informed the resident that the medication was available for use whenever he was ready, then left the room. Review of the facility's policy confirmed that self-administration of medications was only permitted with a physician's order and interdisciplinary team determination, which was not present in this case.
Failure to Assess and Authorize Self-Administration Before Leaving Medication at Bedside
Penalty
Summary
The facility failed to obtain a physician's order and conduct an assessment for self-administration of medication before leaving a prescribed inhaler in a resident's room. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and macular degeneration, was observed with a Breo Ellipta inhaler on their bedside table. The resident reported that an LPN left the inhaler in the room after being called away to attend to another resident, and stated that they had previously self-administered medications prior to admission and were interested in continuing to do so. However, there was no documentation of an order or assessment authorizing self-administration or bedside storage of the medication. Facility policy required an interdisciplinary team assessment and a physician's order before permitting self-administration of medications or leaving medications at the bedside. Interviews with the LPN, DON, and Administrator confirmed that these steps had not been completed for this resident. The DON and Administrator both acknowledged that the resident had not been assessed for self-administration and did not have the necessary physician's order, despite the resident's cognitive ability to self-administer medications.
Failure to Complete Required Annual Self-Administration Medication Assessment
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the ability to self-administer medications as required by policy. Record review showed that a resident with legal blindness, absence of one eye, and peripheral vascular disease was cognitively intact and had severe vision impairment. The resident was self-administering several medications, including Calcium-Vitamin D, Ammonium Lactate lotion, and Omega-3, with physician orders allowing medications at bedside. However, the Medication Self-Administration Safety Screen assessment had not been updated since the initial assessment, and no annual reassessment had been completed as required. Interview with the President of Clinical Operations confirmed that the required annual reassessment was not performed. Policy review indicated that self-administration should only occur if the physician and interdisciplinary team determine the resident can do so safely, but this process was not followed for the resident in question.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to determine if residents were clinically appropriate to self-administer their medications, affecting two residents. Resident #7, who was cognitively intact and required assistance for activities of daily living, was observed self-administering multiple medications, including insulin and inhaled medication, without a self-administration assessment or physician order. The Director of Nursing confirmed that no assessment or order was in place for Resident #7 to self-administer medications. Similarly, Resident #10, who was also cognitively intact, was observed applying Lidocaine patches and keeping Flonase at the bedside for self-administration without a self-administration assessment or physician order. The Director of Nursing verified that Resident #10 did not have a completed self-administration assessment and was not documenting the administration of Flonase, as the nurses were doing that. The facility's policy requires an interdisciplinary team assessment and a physician order for residents to self-administer medications, which was not followed in these cases.
Failure to Securely Store Self-Administered Medications
Penalty
Summary
The facility failed to ensure that a resident, who had an order to self-medicate, stored his medications appropriately. The resident, who was the only one in the facility self-medicating, had a medical history including type two diabetes mellitus, hypertension, and schizophrenia. The physician's order allowed the resident to keep medications at his bedside and self-administer them. An assessment indicated that the resident demonstrated secure storage for medication in his room, and the care plan included interventions to assist the resident in securing his medication and educating him on proper storage. However, during an interview, the resident revealed that he did not have a lock box for his medications and kept them in a cardboard box next to his bed. Observations confirmed that the medications were not securely stored, as they were in an unlocked drawer. Interviews with the Director of Nursing and a Regional Nurse confirmed that the medications were not locked, and the resident had removed the lock from his drawer. The facility's policy required medication storage to be accessible only to authorized personnel and locked when unattended, which was not adhered to in this case.
Failure to Ensure Clinical Appropriateness of Self-Administered Medications
Penalty
Summary
The facility failed to ensure that a resident's right to self-administer medications was clinically appropriate. Resident #78, who had intact cognition and a history of asthma, was found to have an albuterol inhaler at his bedside, which he used without informing the nursing staff. The resident confirmed that he self-administered the inhaler as needed for shortness of breath but did not communicate this to the nurses. The medical record review revealed no documentation of albuterol administration, and there was no assessment titled Medication Self-Administration Safety Assessment for the resident. The facility's policy required an interdisciplinary team to determine the clinical appropriateness of self-administration and to secure the medication properly in the resident's room, which was not followed in this case. Interviews with the resident, an LPN, and the Director of Nursing (DON) confirmed that the resident self-administered the medication without proper assessment or documentation. The DON acknowledged that any resident wishing to self-administer medications should be assessed for safety and appropriateness, and this assessment should be documented in the resident's medical record. However, a facility-generated report indicated that no residents were currently approved to self-administer medications, highlighting a discrepancy between policy and practice. The facility's failure to conduct the necessary assessments and ensure proper documentation led to this deficiency.
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