F554 – Self-Administration of Medications

F554 in Appendix PP of the State Operations Manual (SOM) affords the residents in nursing homes the right to self-administer medications if the interdisciplinary team has determined the practice is clinically appropriate. The interdisciplinary team is referenced in the regulatory language as being defined in the Comprehensive Care Plan regulation (F657) and includes the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition staff, the resident and their representative, other staff or professionals as determined by the resident’s needs or as requested by the resident.

When a resident requests to self-administer medications, the nursing home must complete a thorough assessment as outlined in the interpretative guidance of F554 which at a minimum must include:

• If the medications are appropriate and safe for self-administration. Consideration should be given to high-risk medications such as anticoagulant medications where errors can be life-threatening.
• The resident’s physical capacity to swallow and open medication bottles. This may require involvement of outside services such as occupational and/or speech therapy to ensure the resident is able to complete these tasks. Speech therapy can also assist with cognitive testing as outlined later in the guidance.
• The resident’s cognitive status such as their ability to name medications that they are currently taking and what they are taking them for.
• The resident’s capability to follow directions, tell time, and understand what medications are to be taken at which times.
• The resident’s comprehension of instructions for the medications such as dose, timing, side effects and what to report to nursing staff.
• The residents understanding of refusal and appropriate steps to take if the resident refuses to take a medication.
• The resident’s ability to safely and securely store medications.

The resident’s request to self-administer medications, the assessment outcome, self-administration of medications, and any attempts the nursing home makes to comply with the resident’s request must be included in the care plan. The assessment and care plan should be reviewed/revised on a routine basis. Best practice would be at least quarterly with MDS’ and upon significant changes. However, staff should be aware of potential changes in condition that would require immediate intervention such as a sudden onset of cognitive changes where the resident may not be safe to self-administer medications when the interdisciplinary team is not present to reassess such as overnight or weekends.  Medications that are included in self-administration should be notated on the physician’s order as well.

A few key things to point out with this regulation based on survey reports include that staff must not leave medications with the resident to self-administer at a later time (such as after they’ve eaten) without an interdisciplinary team assessment completed first and the interventions being care planned. As an example, if the surveyor completes observations of residents in their room and notes a medication cup of pills at the resident’s bedside, there should be an assessment and care plan that indicates the resident is safe to self-administer medications.

If a resident requests to self-administer medications and the assessment indicates they are safe to complete parts of the process but not all, the nursing home must make efforts to allow the resident to complete those parts. For example, if the resident does not have the finger/hand dexterity to complete unlocking a box, opening medication bottles, and retrieving individual pills but can identify the medications, ensures they are safe from other residents, and appropriately self-administers the medications the nursing home should allow the aspects the resident is safe completing. Documentation should support the efforts the nursing home completed to comply with the resident’s request.

Examples of non-compliance include when the resident requested to self-administer medications and the nursing home did not comply with the resident’s request and/or the staff left medications at the resident’s bedside without completing an assessment to determine if the resident is safe to self-administer medications.

LeadingAge has resources available including policies and procedures and a template assessment that can be used to ensure compliance.