| 18 |
BENEFIS SENIOR SERVICES |
275012 |
2621 15TH AVE S |
GREAT FALLS |
MT |
59405 |
2019-07-11 |
554 |
E |
0 |
1 |
01HJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to follow the self-administration of medication assessment, and maintain self-administration practices, for 3 (#s 47, 65, and 530) of 45 sampled and supplemental residents. Findings include: [NAME] During an observation and interview on 7/9/19 at 8:31 a.m., resident #47 was resting in his bed, with the head of the bed raised to 30 degrees. The lights in his room were off, and a plastic medicine cup filled with different medications was on his bedside table, which was placed parallel to resident #47's bed and within the resident's reach. No staff were observed in resident #47's room. Resident #47 stated, (Staff) must have left the cup of medications here .They usually do not let (medications) just sit like that. Resident #47 did not know when staff had brought the medication cup into his room and was unsure which medications he took in the mornings. Resident #47 did not know the name of the nurse in charge of his care that day. During an observation and interview on 7/9/19 at 8:38 a.m., staff member U entered resident #47's room to answer a call light. After assisting resident #47 with the urinal, she looked at the cup of medications, picked it up, and walked out of the room with the cup in hand. Staff member U stated if staff find medication cups with medications in the residents' rooms, they are to give them to the nurse. Staff member U then gave resident #47's medication cup to staff member B, who stated, Oh, I thought he took those. Review of resident #47's Self Administration of Medications form, dated 5/2/19, showed resident #47 requested he self-administer medications; however, upon assessment, it was determined resident #47 could neither safely self-administer medications, nor could he leave medications at the bedside. B. During an observation on 7/9/19 at 12:12 p.m., staff member H placed a medication cup with two unidentified tablets on the dining room table next to resident #65's water cup prior to lunch. Staff member H did not say anything to resident #65 about the medication and proceeded to walk away from the dining room table, and other residents were at the table. During an interview on 7/9/19 at 12:15 p.m., staff member H stated the medications were just Tums, and added that resident #65 self-administered Tums after lunch. During an observation on 7/10/19 at 9:54 a.m., staff member T administered medications to resident #65. After administering resident #65's oral medication, staff member T poured two Tums tablets into a plastic medication cup and left it on the dining room table. Staff member T stated resident #65 preferred to take Tums after she was done eating breakfast. Staff member T stated self-administration of Tums after meals should be in resident #65's care plan. Review of resident #65's current care plan did not reveal information about self-administration of medications. Review of resident #65's Admission Assessment, dated 4/20/18, showed resident #65 responded, No, to the following questions: Does rdt/pt want to self administer their own medications? And, Does the rdt/pt want medications to be left at bedside/at their table? (sic) Review of an Interdisciplinary Team note, dated 7/10/19 at 11:08 a.m., and signed by staff member T showed, Okay for (resident #65) to take scheduled morning Tums after meals and at the bedside after meals VORB per (provider). The note did not show approval for self-administration of medications. C. During an observation and interview on 7/10/19 at 8:35 a.m., staff member T pre-poured resident #530's medication and walked into the resident's room. Staff member T placed the medicine cup next to the resident's bedside on the table and walked out of the room to fill a cup of water. She then went back to the room and observed resident #530 take his medications from the medication cup which she had left previously. Staff member T stated leaving medications unattended at the bedside would be allowed if it were written in the resident's care plan. Staff member T was unsure if self-administration of medications was written in resident #530's care plan. She added she would always stay at the bedside of any resident to ensure they had taken all of their medications; otherwise, someone could come in and take the medications if staff were to leave medications unattended. Review of resident #530's Admission Assessment, dated 7/2/19, showed resident #530 answered No to the question, Does the rdt/pt want to self administer their own medications? (sic) Review of an Interdisciplinary Team Note, dated 7/10/19 at 10:39 a.m., and signed by staff member G, showed resident #530, .asked to self administer [MEDICATION NAME] eye drops. Order received from (provider) to self administer and leave at bedside. The note did not mention self-administration had been requested or approved for other medications. Review of the facility's Health System Policy/Procedure titled, Bedside Storage of Medications and Self Administration of Medications, with a revision date of (MONTH) (YEAR), showed, Nursing .obtains a written order for the bedside storage of medication and places the order in the resident's medical record .Uses self administration assessment form to evaluate resident. |
2020-09-01 |