Windsor Gardens Convalescent Hospital

During a concurrent interview with Licensed Vocational Nurse 2 (LVN 2) on 7/17/2024 at 2:53 p.m. and observation of Resident 2, LVN 2 observed Resident 2 ' s Tums bottle with 4 tablets on top Resident 2 ' s bedside table and a lactulose bottle on another bedside tablet. LVN 2 stated Resident 2 was not allowed to take or keep his own medications at bedside. LVN 2 stated there had to be a self-administration assessment completed, a care plan and a physician ' s order when residents wished to take his/her own. LVN 2 reviewed Resident 2 ' s physician ' s orders and verified there was no physician ' s orders indicating Resident 2 could keep his own medications or self-administer them.

During an interview with Director of Nursing (DON) on 7/18/2024 at 3:33 p.m., DON stated there had to be an order in place if resident wished to take his own medication at bedside. DON stated a care plan also had to be in place as the resident was at risk of complications due to medications.

A review of the facility ' s P&P titled, Self-Administration of Medications, reviewed on 12/14/2023 indicated, The Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: the medication is appropriate for self-administration; the resident is able to read and understand medication labels; the resident can follow directions and tell times to know when to take the medication; the resident comprehends the medication ' s purpose, proper dosage, timing, signs of side effects and when to report these to the staff; the resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow the medications; and the resident is able to safely and securely store the medication . if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan . for self-administering residents, the nursing staff determines who is responsible (the resident or the nursing staff) for documenting that medications are taken.

A review of the facility ' s P&P titled, Bedside Medication Storage, reviewed on 12/14/2023 indicated, Bedside medication storage is permitted for residents who are able to 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 . bedside storage of medication is indicated on the resident medication administration record (MAR) and the medication label for the appropriate medications.

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