Unauthorized Medication at Bedside Without Physician Order
Penalty
Summary
A resident was found to have Debrox ear wax removal drops at their bedside without a physician's order. The medication was brought in by a friend, and the resident could not recall when it was received. The resident had a history of lack of coordination, bed confinement, and falls, and was at risk for adverse reactions due to polypharmacy, as documented in their care plan. The resident was assessed as having intact cognitive function and the capacity to make decisions. During medication administration, a Licensed Vocational Nurse (LVN) did not initially notice the ear drops at the bedside and later confirmed that friends and family should be educated about bringing medications into the facility. The facility's policy required that all medications be identified and ordered by a physician, and the Director of Nursing (DON) stated that medications should not be kept at the bedside due to safety concerns. The facility failed to ensure that the resident did not keep medication at the bedside without proper authorization, as required by policy.