Unauthorized Medication Left at Bedside
Penalty
Summary
A deficiency occurred when a resident was found with an over-the-counter medication, Omeprazole 20 mg, left at the bedside without proper authorization or assessment for self-administration. The resident, who was cognitively intact and had multiple diagnoses including a displaced fracture, anemia, chronic pain syndrome, alcohol abuse, and anxiety disorder, was observed with the medication bottle on her bedside table. There was no evidence in the care plan, physician's orders, or assessments that the resident was permitted or assessed to self-administer medications. Additionally, there was no interdisciplinary meeting or documentation supporting self-administration for this resident. Staff interviews confirmed that medications, including over-the-counter drugs, are not allowed to be left at the bedside unless the resident has been properly assessed and authorized to self-administer. The CNA, LPN, physician, and DON all stated that the medication should not have been at the bedside and that the resident was not permitted to self-administer. Facility policies reviewed also required assessment and physician orders for self-administration and specified that medications should not be left in resident rooms if they could cause harm.