Medication Left at Bedside Without Assessment or Order
Penalty
Summary
A deficiency occurred when a registered nurse (RN) left a prescribed medication, Nystatin mouth and throat suspension, at a resident's bedside for self-administration without direct supervision. The resident, who had no cognitive impairment as indicated by a BIMS score of 15 and received medications via an enteral feeding tube, was observed to have the medication left at the chair side table to take later. The nurse exited the room and closed the door, leaving the resident to self-administer the medication without nurse visualization. Review of the resident's records showed there was no assessment for self-administration of medications, no care plan reflecting permission for self-administration, and no provider order authorizing this practice. Facility policy required an interdisciplinary team assessment, a care plan, and a provider order for self-administration of medications, none of which were present in this case. The Director of Nursing confirmed that the required assessment and documentation were not completed for this resident.