Medication Left at Bedside Without Authorization
Penalty
Summary
A deficiency was identified when a resident was found with a medication, specifically a calcium carbonate tablet, left at their bedside without proper authorization or assessment for self-administration. The resident, who had multiple diagnoses including a fracture, hypertension, COPD, muscle spasm, GERD, depression, atherosclerotic heart disease, and osteoarthritis, was observed lying in bed with a cup containing the tablet on the bedside table. The resident stated that the tablet was difficult to swallow and that staff would often leave it on the table, despite his requests for it to be crushed or given with applesauce. There was no care plan, physician's order, or assessment in place permitting the resident to self-administer medication, nor was there documentation of an interdisciplinary meeting regarding self-administration. Staff interviews confirmed that the medication should not have been left at the bedside. A CNA was unable to identify the contents of the cup and deferred to the nurse, who acknowledged the error and noted the potential for other residents, such as those with dementia, to access the medication. The DON confirmed that facility policy prohibits leaving medications or vitamins at the bedside unless there is a specific self-administration order, and that no residents currently have such orders. Review of facility policy further supported that self-administration is only permitted following appropriate assessment and physician determination.