Failure to Ensure Safe Medication Storage and Self-Administration Procedures
Penalty
Summary
The facility failed to ensure that medications were not left at residents' bedsides without a physician's order and did not follow its own policy regarding resident self-administration of medication. Multiple residents were observed with various medications, including eye drops, calcium supplements, artificial tears, albuterol inhalers, analgesic creams, and prescription medications, stored at their bedsides or in personal storage areas. In several cases, residents reported self-administering these medications because nursing staff either forgot to provide them or were too busy, and there was no documentation of physician orders or assessments for self-administration. Staff interviews confirmed that medications should not be left at bedside without a physician's order and that an interdisciplinary team (IDT) assessment and care plan are required for residents to self-administer medications. However, staff allowed residents to keep and use medications at bedside without following these procedures. In one instance, a nurse provided a resident with house stock Voltaren cream that was shared among multiple residents, contrary to policy. Another resident had multiple over-the-counter and prescription medications stored in her closet and bedside dresser, which she accessed and used independently. Review of facility policies indicated that residents may only store medications at bedside with a physician's order and after an assessment of their ability to self-administer. Despite these requirements, the facility did not conduct the necessary assessments or obtain physician orders for the residents observed with medications at bedside. The facility's Director of Nursing and other staff acknowledged that these practices were not in compliance with facility policy or regulatory requirements.