Unauthorized Resident Medication Storage and Self-Administration
Penalty
Summary
A resident with diagnoses of ADHD, anxiety, and hypertension was found to have multiple prescription medication bottles, including Adderall, Atarax, and Diovan, stored at the bedside and inside a dresser drawer. The resident was observed self-administering medication without staff supervision, stating that he took his medications as needed and that staff were aware of this practice. The resident's medical records indicated he had intact cognitive skills and was independent in most activities of daily living, but there was no documentation of an order or care plan allowing self-administration of medications. Interviews with nursing staff, including an LVN and an RN, confirmed that facility policy prohibits residents from keeping medications at their bedside, regardless of whether the medications are prescription or over-the-counter. Staff stated that this practice is unsafe due to the risk of overdose, medication errors, and potential for other residents to access the medications. Both the LVN and RN indicated that medications found at the bedside should be removed immediately and that all staff are responsible for ensuring compliance with medication storage policies. The Director of Nursing confirmed that the resident had not been authorized to self-administer medications and that there was no request or assessment for self-administration on file. Facility policies reviewed indicated that only licensed personnel or authorized staff may access medication supplies, and self-administration is only permitted following a determination by the physician and care planning team. The presence of multiple medication bottles at the resident's bedside and the lack of staff awareness or intervention constituted a failure to follow established medication storage and administration protocols.