Medications Left at Bedside Without Self-Administration Order
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including muscle weakness, glaucoma, hypertensive heart and chronic kidney disease, was observed self-administering medications that had been left at the bedside by a registered nurse. The resident was cognitively intact and received several medications daily, as documented in the care plan and physician's orders. Despite this, the resident did not have an order permitting self-administration of medications. The nurse reported routinely leaving medications at the bedside because the resident preferred to take them later, and confirmed that she did not observe the resident taking the medications, even though she had signed off on the medication administration record (MAR) as if the medications had been administered. Further interviews with facility staff, including the nurse manager, confirmed that medications should not have been left at the bedside and that staff are required to observe residents taking their medications unless there is a specific self-administration order in place. The facility failed to provide a medication administration policy when requested. The facility's own policy on self-administration states that such practice is only permitted if the interdisciplinary team determines it is safe, which had not occurred in this case.