Health inspection·May 9, 2024

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to complete a self-administration of medication assessment for two residents (Resident #294 and Resident #648) out of ten residents sampled as evidenced by an observation of a blue spray bottle labeled Immune Support Bio-active silver hydrosol at Resident # 294's and a box labeled Diclofenac Sodium Topical Gel 1 % ointment and a bottle labeled Valerian Extract supplement at Resident #648's. Both residents did not have a self-administration of medication assessment on file. There were 296 residents residing in the facility at the time of survey. Residents Affected - Few On 05/06/2024 at 12:05 PM an observation was made of a blue spray bottle labeled Immune Support Bio-active silver hydrosol at bedside of Resident #294. On 05/06/2024 at 12:05 PM Staff A, Registered Nurse (RN) stated: I am the nurse assigned to [Resident #294]. I am not aware of [Resident #294] being able to self-medicate or keep medications at the bedside and I will follow up with the supervisor. Staff A, RN removed medication from bedside. Record review of demographic sheet for Resident #294 revealed an admission date of 4/19/2024 with diagnosis that included Thrombocytopenic Purpura. Record review of admission Minimum Data Set (MDS) dated [DATE], Section C for cognitive status revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Section GG for functional status revealed the resident set up/clean up assistance for eating/oral hygiene, substantial maximal assistance for toileting/ upper body dressing, and dependent for shower/bathe/transfer. Record review of activities of daily living deficit related weakness care plan initiated 4/20/2024 for Resident #294 revealed interventions included totally dependent for bathing, dressing and toileting with the assistance of one to two people. Record review of physician orders for Resident #294 on 05/06/2024 revealed no order found for Immune Support Bio-active silver hydrosol. Record review of assessments revealed no self-administration of medication on file. On 05/09/2024 at 12:22 PM Staff C, RN, stated: I am the charge nurse for this unit. For a resident to be allowed to self-medicate, a self-administration of medication assessment must be completed and an order from the doctor obtained. A self-administration of medication assessment was completed for [Resident #294] after the surveyor brought it to our attention that the medication was in the room. Page 1 of 2 105030 105030 05/09/2024 Miami Jewish Health Systems, Inc 5200 NE 2nd Avenue Miami, FL 33137

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 05/06/2024 at 9:47 AM in Resident #648's room revealed a box labeled Diclofenac Sodium Topical Gel 1 % ointment and a bottle labeled Valerian Extract supplement at the resident's bedside. (photo evidence) On 05/06/2024 at 9:47 AM, Resident #648 stated: I use the ointment when the nurse isn't available and the drops to assist with falling asleep. On 05/06/2024 at 12:21 PM Staff B, RN stated: I am not aware of [Resident # 648] being allowed to self-medicate. Staff B, RN entered the room with the surveyor and Staff B, RN removed medications from the bedside and stated I will follow up with charge nurse and physician. Record review of demographic face sheet for Resident # 648 revealed an admission date of 4/28/2024 with diagnosis that included Aftercare following joint replacement surgery, need for assistance with personal care. Record review of the 5-day MDS dated [DATE] Section C revealed a BIMS score of 11, indicating moderate cognitive impairment. Section GG revealed Resident #648 was independent with eating, supervision or touching assistance for oral hygiene and partial moderate assistance for toileting. Record review of physician orders revealed an order dated 4/28/2024 for Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical) Apply to Whole Body topically four times a day for Joint Pain. No physician orders noted at that time for Valerian Extract. Review of the care plans documented self-care deficit and is at risk for further decline related to (r/t) Activity intolerance, Impaired mobility, Recent surgery to right knee, generalized weakness Care Plan initiated on 04/30/2024 revised on 04/30/2024. Interventions included ok for patient to self-administer Valerian Extract supplement, initiated on 05/06/2024. Record review of assessments revealed no self-administration of medication assessment on file. On 05/09/2024 at 11:22 AM Staff D, Licensed Practical Nurse (LPN) stated: I am the charge nurse of this unit. Residents can self-administer medications once a physician's order is obtained. No medications should be kept in the room without a physician's order. [Resident #648], brought this medication from the hospital and staff were not aware of medications being in the room. I spoke to the doctor and an order was obtained for [Resident # 648] to keep the herbal extract in room and the ointment was removed. On 05/09/2024 at 10:23 PM The Director of Nursing (DON) stated that any resident who wishes to self-administer medication, a self-administration assessment must be on file. Record review of Policy and Procedure entitled: Preparation and General Guidelines April 2018. IIA10: Self-Administration of Medications. Policy: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Procedures: A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process. 105030 Page 2 of 2