Health inspection·September 25, 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, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 1 of 1 resident reviewed for self-administration of medications, of a total sample of 39 residents, (#57). Residents Affected - Few Findings: Resident #57 was admitted to the facility on [DATE] with diagnoses including pneumonitis due to inhalants of food and vomit, adult failure to thrive, hypertensive heart disease, anemia, CVA with Left-sided hemiparesis. Review of the Minimum Data Set admission assessment with an assessment reference of 8/30/24 revealed resident #57 had a Brief Interview for Mental Status score of 2 out of 15, which indicated she was severely cognitively impaired. On 9/23/24 at 11:59 AM, resident #57 was observed lying on her back in bed watching television. Her nightstand had a square basket with personal items, including a bottle of 15 millimeter (ml) Visine eye drops and B& C Ointment wound dressing with a 60-gram tube observed at the bedside. The resident, unable to communicate verbally pointed to a paper with a phone number for her daughter. Resident #57's daughter was then interviewed by telephone. She said she brought the eye drops to the facility and placed the bottle in the basket on her mother's nightstand. The daughter also stated she put the drops into her mother's eyes each time she visited because the drops made her eyes feel better. She stated her mother used eye drops previously when she was at home. On 9/23/24 at 2:01 PM, the resident's nightstand was observed by assigned Registered Nurse (RN) A. She acknowledged the Visine eye drops 15 ml and B& C Ointment wound dressing 60 grams tube. A few minutes later she reviewed the resident's physician orders and acknowledged there were no orders for the Visine eye drops and B & C ointment found on the resident's nightstand. RN A explained before a resident could self-administer medication, they must have a self-administration evaluation completed and a physician order initiated. RN A confirmed there was no order for the Visine eye drops or the B & C ointment. She also confirmed the resident had not had a self-administration evaluation to determine if she was able to self administer the medications. On 9/25/24 at 9:36 AM, the Director of Nursing stated the self-administration assessment should be done by the Interdisciplinary Team (IDT) to ensure the resident could safely self-administer medications. She acknowledged resident #57 would not be safe to self-administer based on her severe cognitive impairment. Page 1 of 2 105904 105904 09/25/2024 Atlantic Shores Nursing and Rehab Center 4251 Stack Blvd Melbourne, FL 32901

F 0554 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy and procedure for Medication Administration dated 8/23 revealed, A resident may only self-administer medications after the (IDT) has determined which medications may be self-administered. Residents Affected - Few 105904 Page 2 of 2