Failure to Assess and Obtain Physician Order for Bedside Medication Storage
Penalty
Summary
A resident was observed with a medication box of triple antibiotic ointment at their bedside, with a handwritten note stating 'may keep at bedside.' The resident had an intact cognitive status, as indicated by a BIMS score of 15 on their most recent assessment. However, there was no documented assessment or physician's order in the clinical record authorizing the resident to self-administer medication or to keep medication at the bedside, as required by facility policy. The policy specifies that bedside medication storage is only permitted for residents who are able to self-administer medications, upon written order of the prescriber and after an interdisciplinary assessment. During interviews, the resident stated that a nurse applied the ointment because it was difficult for them to do so. The LPN confirmed that they had written the note on the medication box and acknowledged that a physician's order was required for bedside medication storage, but could not locate such an order for this resident. The DON also confirmed that an assessment and physician's order were necessary and that neither was present for this resident. These findings indicate that the facility failed to assess the resident for self-administration of medication and did not obtain the required physician's order.