Medication Left at Bedside Without Self-Administration Evaluation
Penalty
Summary
A deficiency occurred when a resident was found with lidocaine, a medication used to relieve pain, left at the bedside without having been evaluated for self-administration. During observation, the resident was seen holding a washcloth to her mouth in apparent pain, with a medication cup containing a clear gel substance on her over-bed table. The resident reported that the nurse provided the lidocaine so she could use it when in pain. Licensed nursing staff confirmed that the medication was left at the bedside and acknowledged that an evaluation is required before a resident is permitted to self-administer medication. However, the resident had not been evaluated for this, nor were there physician orders or a lock box present as required by facility policy. Further interviews with nursing staff and the Director of Nursing confirmed that the resident did not have physician orders to self-administer medications and that the lidocaine should not have been left at the bedside. Review of the facility's policy indicated that an interdisciplinary team assessment is necessary to determine if self-administration is safe and appropriate, considering the resident's cognitive and physical abilities. In this case, the required assessment and procedures were not followed, resulting in the medication being accessible to the resident without proper authorization or safeguards.