§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
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Observations:
Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for two of 24 sampled residents. (Residents 54 and 118)
Findings include:
Review of the facility policy entitled, "Medications: Self-Administration," last reviewed May 15, 2026, revealed that a resident may exercise the right to self-administer medications when determined that this practice was safe. It was the responsibility of the Interdisciplinary Team to determine the following issues with regards to resident self-administration of medications: resident safety to self-administer medications, location of medication administration, determine who would be responsible for storage, and documentation of medication administration. If the resident indicated a desire to self-administer his or her medications, the Interdisciplinary Team would complete the "Self-Administration of Medications UDA (User Defined Assessment)" to determine the resident's ability to safely self-administer medications. The Care Plan would document interventions to support self-administration of medications by the residents.
Clinical record review revealed that Resident 54 was admitted to the facility on June 6, 2024, and had diagnoses that included diabetes, emphysema (a chronic lung condition that causes shortness of breath due to damage to the air sacs of the lungs), and chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe). Review of the Minimum Data Set (MDS) assessment, dated April 2, 2026, revealed that Resident 54 was alert and oriented. Observation on June 23, 2026, at 11:13 a.m., revealed a prescribed inhaler was on the resident's bedside table. In an interview on June 23, 2026, at 11:13 a.m., the resident stated that he was permitted to administer the medication by himself. There was no documentation to support that the resident had a physician's order to self-administer medications or that the interdisciplinary team had assessed the resident to self-administer medications.
Clinical record review revealed that Resident 118 was admitted to the facility on July 24, 2025, and had diagnoses that included colon cancer, heart disease, and kidney disease. Review of the MDS assessment, dated May 18, 2026, revealed that Resident 118 was alert and oriented. Observations of the resident's tray table on June 23, 2026, at 11:12 a.m., June 24, 2026, at 9:01 a.m., and on June 26, 2026, at 11:35 a.m., revealed an open tube of prescription silver sulfadiazine topical cream. In an interview on June 24, 2026, at 1:29 p.m., the resident stated that he was permitted to administer the medication by himself. There was no documentation to support that the resident had been assessed to self-administer medications.
In an interview on June 26, 2026, at 11:15 a.m., the Nursing Home Administrator confirmed that Residents 54 and 118 did not have a physician's order to self-administer medications, and the residents were not assessed to self-administer the medications.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 08/11/2026
Residents 54 and 118 identified during the survey were immediately assessed by the interdisciplinary team to determine their ability to safely self-administer medications. Any medications maintained at the bedside without appropriate authorization were removed until comprehensive assessment was completed. Physician notification was made as indicated, physician orders were obtained, and resident care plan was updated to reflect the determination regarding self-administration.
A facility-wide audit of current residents was completed to identify any resident who was self-administering medications or maintaining medications at bedside. Each identified resident received an interdisciplinary assessment, medication safety, and appropriateness for self-administration. Physician orders and care plans were reviewed and updated as necessary.
The DON/designee will provide education on F tag 554 with focus on resident self-administration of medication policy and procedure reviewed. DON/designee will verify that all residents approved for self administration have appropriate assessments, physician orders, care plans, and secure medication storage .
The DON/designee will conduct weekly audits x 4, monthly x 2 of residents approved for self-administration of medication to ensure compliance with policy.
Audit findings will be reported to the Quality Assurance Performance Improvement Committee monthly.
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