Penalty

Fine: $114,300

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

Facility staff failed to ensure that a resident was properly assessed for self-administration of medication, as required by facility policy. During the survey, an over-the-counter bottle of Thera-Flu Max was observed at the bedside of a resident who reported self-administering the medication daily for congestion. The resident had a history of cerebral infarct, hemiplegia, cognitive communication deficit, and asthma, but demonstrated no cognitive impairment with a BIMS score of 15 out of 15 and required assistance with activities of daily living. Upon review, there was no documented assessment or physician order authorizing self-administration of the medication or allowing the medication to be kept at the bedside. Staff interviews confirmed that no residents on the unit had completed assessments or orders for self-administration of medications. Facility policy requires an interdisciplinary team determination for clinical appropriateness and safety before permitting self-administration, which was not completed in this case.