Unattended Medications Left at Bedside Without Authorization
Penalty
Summary
A deficiency was identified when medications, specifically a tube of barrier cream and anti-fungal powder, were found unattended on a resident's bedside table during two separate observations. The resident had a history of lumbar vertebra fracture and was cognitively intact, as indicated by a BIMS score of 13. Physician orders were present for the barrier cream but not for the anti-fungal powder, and there was no evidence of an order or assessment for self-administration of medications. The care plan and clinical record lacked documentation supporting the resident's ability or authorization to self-administer medications. Interviews with staff revealed that medications, including topical treatments, are not to be left at the bedside unless there is a provider order and a completed self-administration assessment. Staff confirmed that family members are required to give any medications they bring to nursing staff, and that medications should be stored in the treatment cart, not in the resident's room. Facility policy also requires that only authorized staff administer medications and that self-administered medications be securely stored. Despite these policies, the medications were left unattended, and there was no documentation supporting self-administration for the resident involved.