Failure to Secure Medications and Ensure Proper Authorization for Bedside Storage
Penalty
Summary
The facility failed to ensure that medications and biologicals were secured at all times, as required by policy and regulation, for two of sixteen sampled residents. For one resident, who had diagnoses including a femur fracture and generalized muscle weakness and was assessed as cognitively intact, medications were observed left at the bedside in two medicine cups, one containing multiple pills and a capsule, and the other containing a liquid medication. The resident and her spouse stated that the medications were left at the bedside because the spouse insisted, and the resident did not recognize all the medications. Facility staff confirmed that there was no physician's order, care plan, or evaluation for self-administration of medications for this resident, and acknowledged that medications should not have been left at the bedside without these in place. For a second resident, who had generalized muscle weakness and required assistance with personal care, a bottle of sterile eye drop lubricant was observed on the overbed table. The resident stated that her husband administered the eye drops for her, but she did not self-administer them. Staff confirmed that there was no physician's order for the eye drops, no evaluation for self-administration, and no care plan for self-administration of medications for this resident. The staff instructed the resident's husband to take the eye drops home and indicated they would obtain an order from the physician. In both cases, the facility's own policies required that medications be stored securely and only accessible to authorized personnel, and that self-administration of medications be permitted only after an interdisciplinary team assessment, a physician's order, and appropriate care planning. These requirements were not met for either resident, resulting in unsecured medications at the bedside without proper authorization or assessment.