Surveyors found that staff left cups containing multiple oral medications with two residents at the breakfast table and then left the area, allowing the residents to take the medications on their own, including one instance where a pill was dropped on the floor. Review of the EMR and staff interviews showed there were no physician orders authorizing these residents to self-administer their routine oral medications, even though each only had limited orders for self-administration of specific treatments (Kenalog paste and nebulizer therapy). Facility policies required an assessment and a physician order for self-administration to be in place before residents could self-administer medications, but this process was not followed in these cases.
A resident was allowed to self-administer nebulizer medications without a documented assessment or care plan for self-administration, contrary to facility policy. An LPN set up the nebulizer and left the resident alone during the treatment, and interviews confirmed that no residents had been assessed for safe self-administration of medications.
Several residents self-administered medications, including inhaled treatments, topical creams, and oral medications, without documented assessments or required physician's orders. Medications were left at the bedside or in resident rooms, sometimes expired or unlabeled, and care plans did not address self-administration or medication storage. Facility staff confirmed that no residents had been formally assessed or authorized for self-administration, contrary to facility policy.
Two residents were allowed to self-administer nebulizer medications without required assessments, physician orders, or care plan documentation. Staff set up the treatments and left the residents unsupervised, contrary to facility policy, which mandates evaluation and authorization before permitting self-administration.
A resident was allowed to self-administer medications, including a nebulizer treatment and nasal spray, in their room without staff supervision or a physician's order, despite an evaluation indicating the resident was not able to self-administer medications. Staff left medications at the bedside, and the DON confirmed the absence of required authorization and assessment per facility policy.
Two residents were allowed to self-administer medications without proper assessments or physician's orders. One resident used a nasal spray for a dry nose caused by oxygen use, while another used a nebulizer for breathing treatments. The facility's policy requiring assessments and orders was not followed.
Two residents were not routinely assessed for safe self-administration of medications, despite having intact cognition and orders for self-administration. One resident had a nasal spray without a self-administration order, and the other had not been assessed for over a year. The facility's policy required quarterly assessments, which were not conducted.
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