LOS ANGELES, CA - A state inspection at Windsor Gardens Convalescent Hospital revealed that staff permitted a resident with chronic obstructive pulmonary disease and diabetes to store and self-administer medications without proper physician authorization or safety protocols in place.
Unauthorized Medication Access Discovered
During a July 2024 inspection, surveyors found a resident keeping Tums tablets and lactulose oral solution at their bedside, which the resident stated they took every two hours. The resident reported that nursing staff were aware of this arrangement, yet facility records showed no physician's order authorizing bedside medication storage or self-administration.
The resident, who required maximum assistance with daily activities including oral hygiene, toileting, and dressing, had multiple medications accessible without the required safety oversight. When inspectors questioned the Licensed Vocational Nurse on duty about the situation, the nurse confirmed the resident was not permitted to keep or take their own medications without proper authorization.
The nurse explained that three critical safeguards must be in place before any resident can self-administer medications: a completed self-administration assessment, an active care plan addressing the practice, and a physician's order. A review of the resident's medical records confirmed none of these required elements existed.
Critical Safety Protocols Missing
While the facility had conducted a medication self-administration evaluation in March 2024 that approved the resident for oral, nasal, and inhaler medications due to limited range of motion, this assessment alone did not constitute proper authorization. The evaluation noted physical limitations that actually restricted the resident's ability to administer certain types of medications safely.
Medical protocols require multiple layers of verification before residents can manage their own medications. Self-administration evaluations must assess whether residents can read medication labels, understand proper dosing and timing, recognize side effects, and physically manipulate medication containers. Beyond the initial assessment, facilities must obtain specific physician orders and implement individualized care plans that address potential risks.
The absence of these safeguards created several concerning scenarios. Lactulose, a laxative medication used to treat constipation, requires careful dosing to prevent dehydration and electrolyte imbalances, particularly problematic for someone with chronic lung disease. Tums, while seemingly benign, contains calcium carbonate that can interact with other medications and affect blood sugar levels in diabetic patients when taken frequently.
Care Planning Failures Identified
The facility's records showed a care plan existed for the resident's "non-compliance manifested by keeping medication at bedside," initiated in March 2024. This care plan set a goal of the resident complying with facility policies and included interventions such as documenting the resident's response to non-compliance and providing redirection as needed.
However, surveyors noted a significant gap: no care plan existed specifically addressing the resident's self-administration of medications. This represented a fundamental breakdown in care planning, as the facility documented the problem behavior but failed to create a structured plan to either properly authorize the practice or prevent it.
The facility's own policies required comprehensive documentation when residents self-administer medications. According to Windsor Gardens' written procedures, the interdisciplinary team must evaluate multiple factors including the resident's ability to understand medication purposes, follow timing instructions, recognize side effects, and securely store medications. The policy explicitly states that self-administration must be documented in both the medical record and care plan.
Regulatory Standards and Best Practices
Federal regulations require nursing homes to ensure medications are administered according to physician orders and professional standards of practice. When facilities allow self-administration, they must demonstrate that residents possess the cognitive and physical capabilities to manage medications safely without supervision.
Industry standards emphasize that self-medication privileges require ongoing monitoring and documentation. Staff must verify that residents taking their own medications do so correctly, at appropriate intervals, and without experiencing adverse effects. The medication administration record should clearly indicate which medications residents self-administer, and medication labels should reflect bedside storage authorization.
The inspection revealed these fundamental safeguards were absent. The resident's medication orders made no mention of self-administration or bedside storage. The nursing staff lacked documentation showing the resident had been cleared to take Tums every two hours or to access lactulose independently.
Additional Issues Identified
The inspection also documented that the resident was taking Tums and lactulose without any physician orders for these medications in their current orders summary. This compounded the authorization problems, as the facility had no documented medical justification for either medication being available to the resident.
The Director of Nursing acknowledged during the inspection that physician orders must be in place before residents can keep medications at bedside, and that care plans addressing self-medication are necessary due to potential complications. This acknowledgment confirmed that facility leadership understood the requirements but had not ensured compliance with their own policies.
The violations demonstrated a breakdown in multiple levels of oversight, from bedside nursing staff who allowed the practice to continue, to care planning teams who failed to address the situation appropriately, to administrative review processes that should have identified the missing authorizations and safety protocols.
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.
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