Medications Improperly Left at Bedside Without Orders or Care Plan
Penalty
Summary
Surveyors found that the facility failed to ensure medications and biologicals were not left at the bedside for two residents. For one resident with a history of protein-calorie malnutrition and bone disorders, medications including an albuterol inhaler, Coricidin D, and a calcium supplement were observed at the bedside. This resident had intact cognition but did not have a care plan or physician's order permitting self-administration of medications. Staff interviews confirmed that the resident was not authorized to self-administer and that medications should have been stored in the medication cart. For another resident with congestive heart failure and moderate cognitive impairment, Coricidin HBP was found on the overbed table without a physician's order. The resident stated they were waiting for physician approval for the medication. There was no care plan or order for self-administration. Multiple staff, including RNs, the Director of Staff Development, the Executive Director, and the DON, confirmed that medications should not be left at the bedside unless specifically care planned and ordered, and that this protocol was not followed in these cases.