Based on clinical record review, review of facility policy, observation and staff interview, it was determined that the facility failed to ensure that the interdisciplinary team assessed a resident's capabilities to self administer medications for one of one sampled resident who self administered medications. (Resident 357)
Review of facility policy entitled "Self-Administration of Medication", dated December 2018, revealed that the facility was to strive to ensure that the resident was properly prepared and clinically appropriate to self -administer medications. Staff was to complete a self-administration evaluation form to determine if the resident was able to self administer medications. The facility was to ensure that the physician's order and care plan reflected the residents ability to self administer medications. In addition, all medications to be self administered were to be stored in a locked medication drawer in the residents room or another designated area and the licensed nursing staff was to monitor parameters and lab values as needed.
Clinical record review revealed that Resident 357 was admitted to the facility on February 8, 2019, with diagnoses that included status post right knee replacement and a history of an upper respiratory infection. Observation on February 13, 2019, at 10:45 a.m., revealed that there was an Aerosol inhaler (Breo Elipta Aerosol) stored in an unlocked bathroom cabinet in the resident's bathroom. Resident 357stated that she was able to use the inhaler on her own. Further observation on February 14, 2019, at 10:00 a.m., and 12:35 p.m., revealed that the Aerosol inhaler was still stored in the unlocked cabinet. Review of the physician's orders revealed that on February 12, 2019, there was an order for staff to administer the Breo Aerosol powder daily for an upper respiratory infection. The order did not include instructions for the resident to be able to self administer the medication. There was no documented evidence that the facility completed the evaluation for the resident to be able to self administer medications, there was no physician's order or care plan for the resident to self administer and the medication was not stored in a locked area as per facility policy.
In an interview on February 15, 2019, at 11:35 a.m., the Director of Nursing stated that the facility had not completed an evaluation, care plan, physician's order nor had the medication stored as per facility policy for the resident to self administer the Aerosol inhaler.
28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/30/18
| ||Plan of Correction - To be completed: 03/08/2019|
On February 13, 2019 after being notified of the medication and the resident's desire to self-administer. Nursing completed assessments and orders were completed per policy and presented to the survey team. Medication was secured in the resident's room.
Resident discharged the community on February 15, 2019.
Rounds were conducted to ensure that there are no unsecured medications in resident rooms. Any other residents that do have medications will be reviewed to ensure that we are operating in compliance with company policy and related regulation. Rounds completed February 28, 2019.
DON or designee will conduct education for all licensed nurses relating to Medication Self-Administration Policy and appropriate intervention to be implemented if resident non-compliance with policy. Education completed by February 28, 2019.
The Care Plan will reflect the resident choice to self-administer medications.
Residents will be asked, by the licensed nurses, upon move-in, if he/she self-administers any medication(s) or chooses to self-administer medications (if applicable).
NHA or designee will provide education relating to Medication Self-Administration and proper Storage of Medications at Resident Council Meetings.
NHA or designee will provide information on Medication Self-Administration and Storage of Medications to residents as part of the move-in process by March 8, 2019.
Weekly rounds will be completed for 3 months to ensure that there are no unsecured medications in resident rooms. Results will be reported to QAPI quarterly.