Unauthorized Medication at Bedside Without Physician Order
Penalty
Summary
A deficiency occurred when a resident was found with a tube of 1% hydrocortisone cream at their bedside without a physician's order or authorization to keep medication at the bedside. The facility's policy requires a prescriber's order and an interdisciplinary team assessment to determine if a resident can safely self-administer medication and store it at the bedside. The resident's medical record did not contain an order for hydrocortisone cream, nor was there documentation of an assessment or care plan permitting self-administration or bedside storage of medication. Observations by the surveyor confirmed the presence of the cream at the bedside on multiple occasions, including once with the cap off. Interviews with the resident, an LPN, and the DON confirmed that the resident did not have an order for the cream or for self-administration, and the medication was not listed on the Medication Administration Record. The resident had intact cognition and was their own medical decision maker, but previous assessments indicated they did not wish to self-administer medication. The facility failed to follow its own policy and regulatory requirements for safe and accurate administration of drugs and biologicals.