Unsecured and Unauthorized Medications Found at Bedside
Penalty
Summary
The facility failed to ensure that residents did not have unsecured and unauthorized medications at their bedside, as evidenced by observations and record reviews for three residents. For one resident with dementia and moderate cognitive impairment, multiple medications including lidocaine cream, hydrocortisone otic solution, and ophthalmic drops were found on the overbed table. There was no care plan or physician order for self-administration of medications, and the DON confirmed the resident was not assessed or approved for self-administration. Similarly, another resident with a history of cataracts, glaucoma, and hemiplegia, but with little to no cognitive impairment, had throat lozenges, medicated ointment, and hydrogen peroxide accessible in the room. The resident reported occasional use of the lozenges, while the ointment and peroxide were applied by staff, yet no assessment or physician order for self-administration was present. A third resident with chronic obstructive pulmonary disease, tremor, and weakness, and also with little to no cognitive impairment, had a container of sore throat spray in the bathroom. The resident stated she used the medication occasionally, but again, there was no assessment or physician order for self-administration. The DON confirmed the presence of the medication and acknowledged that the resident was not assessed for self-administration. In all cases, the facility did not document assessments or obtain physician orders for self-administration, resulting in residents having unauthorized medications accessible in their rooms.