Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The facility failed to follow its policy regarding self-administration of medications by not ensuring that residents had physician orders for medications stored at the bedside and were properly assessed for their ability to self-administer. One resident was observed with a bottle of refresh eye drops on the bedside table and reported that nurses had been administering the medication since admission, stating an inability to self-administer and waiting for nursing staff to provide the drops. This resident was found to be cognitively intact with a BIMS score of 15, but there was no physician order for the eye drops or for self-administration or bedside storage. Another resident was observed with a container of oral antidiarrheal medication at the bedside and reported intermittent diarrhea due to a medical condition. The resident stated that the facility did not provide the medication when requested, so a family member brought it in for self-administration as needed. This resident had a BIMS score of 12, indicating moderate cognitive impairment, and there was no physician order for the medication, self-administration, or bedside storage. The facility's policy requires an interdisciplinary team assessment and a physician order before allowing self-administration or bedside storage, which was not followed in these cases.