Medications Left at Bedside Without Clinical Assessment for Self-Administration
Penalty
Summary
A resident with moderately impaired cognitive skills, as documented in her Minimum Data Set (MDS) assessment, was found to have at least six different medications left at her bedside for self-administration. The resident did not respond verbally to questions about the medications. Nursing staff confirmed that the medications were her morning doses and acknowledged that medications should not be left at the bedside. The nurse responsible for leaving the medications stated he was working an extra shift and gave out medications early, confirming he should not have left them unattended. Further review of the resident's electronic health record revealed no assessment had been completed to determine if she was clinically appropriate to self-administer her medications. The Director of Nursing confirmed the absence of such an assessment and stated that, given the resident's cognitive status, she would not be appropriate for self-administration. The facility's policy on self-administration of medications was requested but not provided before the survey exit.