Federal inspectors found the resident at Windsor Gardens Convalescent Hospital self-administering medications without the required physician orders, safety assessments, or care plans that the facility's own policies demanded.
The resident was admitted with chronic obstructive pulmonary disease, difficulty swallowing, and type 2 diabetes. His cognitive abilities were intact for daily decision-making, but he required maximum assistance from staff for basic activities like oral hygiene, toileting, and dressing.
In March, staff had completed a medication self-administration evaluation that approved the resident to handle only oral, nasal, and inhaler medications because his range of motion was too limited for other types. But no care plan was ever implemented for this self-administration approval.
When inspectors observed the resident on July 17 at 2:44 p.m., they found a Tums bottle containing three tablets and a small green tablet on top of his bedside table. A lactulose oral solution sat on another bedside table. The resident told inspectors he took his Tums every two hours and that nurses were aware he kept his medications at bedside and administered them himself.
Nine minutes later, Licensed Vocational Nurse 2 arrived for her own interview with inspectors. She observed the Tums bottle, now containing four tablets, still sitting on the resident's bedside table alongside the lactulose bottle.
The nurse immediately recognized the violation. She told inspectors the resident was not allowed to take or keep his own medications at bedside. She explained there had to be a self-administration assessment completed, a care plan, and a physician's order when residents wanted to manage their own medications.
The nurse reviewed the resident's physician orders on the spot and verified there were no orders indicating he could keep his own medications or self-administer them.
Nobody had written orders for the Tums or lactulose. The facility's Order Summary Report as of July 18 showed no physician authorization for either medication, and no orders allowing the resident to keep and store personal medications at his bedside.
The Director of Nursing confirmed the next day that an order had to be in place if a resident wanted to take his own medication at bedside. She stated a care plan also had to be implemented because the resident was at risk of complications from medications.
The facility had detailed policies governing exactly this situation. Their Self-Administration of Medications policy, reviewed in December 2023, required the interdisciplinary team to consider multiple safety factors before allowing self-administration. These included whether the resident could read medication labels, follow directions, understand timing, comprehend the medication's purpose and proper dosage, recognize side effects, and safely store the medication.
The policy stated that if self-administration was deemed safe and appropriate, "this is documented in the medical record and the care plan."
The facility's Bedside Medication Storage policy was equally specific. It permitted bedside storage only for residents who could self-administer medications, "upon the written order of the prescriber and when it is deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team."
The policy required that bedside storage be indicated on both the resident's medication administration record and the medication label.
None of these safeguards were in place for this resident.
The resident had a care plan for "non-compliance manifested by keeping medication at bedside" that was initiated on March 27. The plan's goal was for him to comply with facility policies and doctor's orders daily. Interventions included documenting his response to non-compliance, notifying him of risks and consequences, and providing redirection as needed.
But there was no care plan addressing his approved self-administration of oral, nasal and inhaler medications, despite the March evaluation that had granted this permission.
The contradiction was stark: the facility had a care plan designed to stop the resident from keeping medications at his bedside, while simultaneously allowing him to do exactly that without proper authorization. Staff knew about the practice, policies existed to govern it safely, but the required physician orders and safety documentation were never completed.
The resident continued taking his Tums every two hours, measuring his own doses of lactulose, while the facility's interdisciplinary team had never formally assessed whether this arrangement was safe for someone with his complex medical conditions and limited range of motion.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Gardens Convalescent Hospital from 2024-07-18 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Windsor Gardens Convalescent Hospital
- Browse all CA nursing home inspections