CMS SOM App. PP, Tag F554

defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

GUIDANCE §483.10(c)(7)

If a resident requests to self-administer medication(s), it is the responsibility of the

interdisciplinary team (IDT) (as defined in §483.21(b), F657, Comprehensive Care Plans) to

determine that it is safe before the resident exercises that right. A resident may only self-administer medications after the IDT has determined which medications may be self-administered.

When determining if self-administration is clinically appropriate for a resident, the IDT should at

a minimum consider the following:

• The medications appropriate and safe for self-administration;

• The resident’s physical capacity to swallow without difficulty and to open medication

bottles;

• The resident’s cognitive status, including their ability to correctly name their medications

and know what conditions they are taken for;

• The resident’s capability to follow directions and tell time to know when medications

need to be taken;

• The resident’s comprehension of instructions for the medications they are taking,

including the dose, timing, and signs of side effects, and when to report to facility staff.

• The resident’s ability to understand what refusal of medication is, and appropriate steps

taken by staff to educate when this occurs.

• The resident’s ability to ensure that medication is stored safely and securely.

Appropriate notation of these determinations must be documented in the resident’s medical

record and care plan. If a resident is self-administering medication, review the resident’s record

to verify that this decision was made by the IDT, including the resident. The decision that a

resident has the ability to self-administer medication is subject to periodic assessment by the

IDT, based on changes in the resident’s medical and decision-making status. If self-administration is determined not to be safe, the IDT should consider, based on the assessment of

the resident’s abilities, options that allow the resident to actively participate in the administration

of their medications to the extent that is safe (i.e., the resident may be assessed as not able to

self-administer their medications because they are not able to manage a locked box in their room,

but they may be able to get the medications from the nurse at a designated location and then

safely self-administer them).

Medication errors occurring with residents who self-administer should not be counted in the

facility’s medication error rate and should not be cited at §483.45(f)(1) F759 and §483.45(f)(2)

F760, Medication Errors. However, this may call into question the judgment of facility staff in

allowing self-administration of medication for that resident.

PROCEDURES AND PROBES §483.10(c)(7)

Determine that facility staff have a process to demonstrate that the resident has taken the self-administered medication.

• Ask residents if they requested to self-administer medications and if they received a

response.

• How do staff determine if a resident is able to safely self-administer medications?

• If the interdisciplinary team has determined that the resident can safely self-administer

medications, was this request honored?

If the interdisciplinary team was not involved in determining whether the self-administration of

medications was clinically appropriate, cite here at F554. If other concerns related to care

planning are identified, see guidance at §483.21, Comprehensive Person-Centered Care

Planning.