Medications Left at Bedside Without Authorization or Labeling
Penalty
Summary
Surveyors identified that the facility failed to ensure medications and biologicals were not left at the bedside for two residents. In the first instance, a resident with multiple diagnoses, including pneumonia, respiratory failure, heart failure, and diabetes, was found with a red tube of antifungal powder at the bedside. The resident stated that staff sometimes left the tube near him or on his table. There was no assessment or physician order for the resident to self-administer medication, and the care plan did not address self-administration. Staff interviews confirmed that medications should not be left at the bedside and that the facility policy requires an assessment and specific orders for self-administration, which were not present for this resident. In the second instance, another resident with a history of cerebral palsy, diabetes, and other chronic conditions was observed with an unlabeled medication cup containing a white ointment and a bottle of ketoconazole shampoo with an illegible label at the bedside. The resident believed the cup contained triad cream used for skin treatment. Review of the care plan and physician orders revealed no authorization for self-administration of medications. Staff interviews indicated that medications, including topicals, should not be left at the bedside and that any found should be removed and given to a nurse or medication technician. Further interviews with nursing staff, including a CNA, LPN, CMA, RN, and the DON, consistently indicated that medications at the bedside are not permitted unless the resident has been assessed and authorized to self-administer. The facility's policy requires medications to be secured at all times, and any self-administration must be care planned and reviewed. The presence of unlabeled or unauthorized medications at the bedside did not meet staff expectations or facility policy, as confirmed by multiple staff members during the survey.