12/18/2025

Survey Tip of the Week: Assessment of Self Administration

One of the most common citations under F554 occurs when staff leave medications at the bedside for a resident who has not been formally assessed or approved to self-administer. Residents have the right to self-administer medications when the interdisciplinary team (IDT) determines it is clinically appropriate. Surveyors will expect facilities to demonstrate a clear, consistent process for assessing whether a resident can safely self-administer, including evaluating their physical abilities, cognitive status, understanding of medication instructions, awareness of side effects, and ability to store medications securely. These determinations must be documented in the medical record and reflected in the care plan, with periodic reassessment when a resident’s condition changes. 

Surveyors will also look for evidence that the IDT, not a single staff member, made the decision, and that resident requests were responded to. When a resident self-administers, facilities must show how they verify that medications were taken as ordered. Medication errors made by residents who self-administer are not included in the facility’s medication error rate; however, such errors may signal that self-administration was not an appropriate IDT decision. If the IDT was not involved or the process was not followed, surveyors will cite F554. 

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