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 resident with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, hypertension, and left arm pain was readmitted to the facility and assessed as moderately cognitively impaired, with a BIMS score of 11 out of 15. The resident did not have a care plan for self-administration of medications, nor was there a physician's order permitting self-administration documented in the electronic medical record. Despite this, during a medication pass, an RN prepared the resident's medications, placed them in a medicine cup, and left the room to retrieve additional Tylenol, leaving the resident unobserved with the medications. The resident then self-administered the medications without direct nurse supervision. Interviews with the RN and the Director of Nursing confirmed that the resident was not authorized to self-administer medications and that facility policy requires nurses to observe residents taking their medications. Review of facility policies further indicated that self-administration must be assessed and documented, and that medication administration should be directly observed by nursing staff. These actions and omissions resulted in a failure to ensure the resident was safe to self-administer medications and that medication administration was properly supervised and documented.