A resident with mild cognitive impairment, multiple medical diagnoses, and a physician order for scheduled DuoNeb nebulizer treatments was repeatedly observed using the nebulizer without staff present, including times when the mask lay on the bed or floor while the machine was running or was held far from the mouth. The care plan documented impaired cognition and the need for supervision and task segmentation, and an intervention to administer treatments as ordered, yet there was no documented self-medication assessment, no care plan direction for self-administration, and no physician order authorizing self-administration, contrary to facility policy requiring an IDT assessment and documentation before allowing self-administration of medications.
A resident was observed in the activity room taking multiple tablets with applesauce while no staff were present, even though the chart had no assessment or order allowing self-administration. The facility policy required observation of medication consumption, and the DON stated the resident should have been supervised because she cannot take her pills without assistance.
A resident with intact cognition and multiple chronic conditions, including A-fib, diabetes, and HTN, was care planned as resistive to care and known to refuse medications, but was not care planned or ordered to self-administer meds. The MAR directed staff to administer three mid-morning pills, and facility policy allowed self-administration only with physician and IDT determination. A CMA placed the medications at the bedside, briefly conversed with the resident, and left the room without administering or confirming ingestion, leaving the meds unattended. The DON and CMAs reported that residents are not permitted to keep meds in their rooms and that staff are expected to remain with residents during administration, while the resident reported that staff periodically leave medications in the room. Facility policy required safe administration as prescribed and restricted self-administration to residents formally assessed and approved to do so.
A resident with diabetes, paraplegia, and spina bifida was allowed to self-administer insulin without a documented assessment of safety or competency, as required by facility policy. The resident independently injected insulin under RN supervision, but the care plan and medical record lacked evidence of an interdisciplinary team assessment or documentation supporting the decision to permit self-administration.
A resident with diabetes, hypertension, and Parkinson's disease was allowed to self-administer insulin without thorough documentation of an assessment to determine clinical appropriateness. Despite staff facilitating the resident's self-administration and a note indicating he managed the task, the care plan and records lacked comprehensive assessment details as required by facility policy.
The facility did not complete required self-medication administration assessments for two residents—one with diabetes and another with severe allergies and an order for an EpiPen at bedside. Both residents were either observed with medications at bedside or had orders to self-administer, but there was no documented interdisciplinary assessment as required by facility policy. Staff were also unaware of one resident's allergies and the location of emergency medication.
A resident with moderately impaired cognition was found with multiple medication cups containing topical creams at bedside, which he self-applied without a physician's order or documented assessment for self-administration. Staff were unaware of the resident's self-administration, and facility policy requiring assessment and secure storage of medications was not followed.
A resident with intact cognition and multiple diagnoses was observed with a diuretic pill at bedside, which staff confirmed was taken only after checking back. The clinical record lacked documentation that the resident was assessed as safe to self-administer medications, contrary to facility policy requiring physician and care team determination before allowing self-administration.
A facility failed to ensure that a resident with moderately impaired cognition could safely self-administer medications. The resident's care plan noted impaired thought processes, yet a bottle of chlorhexidine gluconate solution was found accessible in the bathroom. The clinical record lacked documentation of the resident's ability to self-administer safely, and the acting DON admitted the mouthwash should have been secured. The Administrator could not find a policy on self-administration of medications.
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