Failure to Ensure Proper Medication Orders and Assessments for Bedside Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents by not ensuring proper physician orders and assessments for self-administration and bedside storage of medications. One resident was observed with melatonin gummies at the bedside without a physician order or a documented self-administration assessment. This resident also did not receive prescribed bedtime medications on a specific date, and there was no documentation that the physician was notified of the missed doses. The resident had intact cognition and made their own medical decisions, but the required processes for self-administration and bedside medication storage were not followed. Another resident was found with a bottle of bovine collagen pills, liquid Imodium, and two albuterol inhalers at the bedside. While the care plan and assessments allowed for self-administration of certain medications, there was no physician order or assessment permitting the resident to keep Imodium at the bedside or to self-administer it. The resident had intact cognition, and the care plan specified which medications could be self-administered, but Imodium was not included among them. A third resident was observed with triamcinolone cream, lidocaine ointment, and elderberry immune health pills at the bedside. The medical record did not contain a physician order or self-administration assessment for these medications to be kept at the bedside. The resident had intact cognition, and the care plan and assessments addressed self-administration for some medications, but not for all those found at the bedside. The facility's policies require physician orders and interdisciplinary team assessments for self-administration and bedside storage, which were not completed for these medications.