Medications Left at Bedside Without Required Self-Administration Assessment
Penalty
Summary
A resident admitted with a diagnosis including muscle weakness and assessed as cognitively intact (BIMS score 15/15) was found to have medications, specifically Tums and Rolaids, at their bedside without a completed self-administration assessment. The resident reported taking the Tums as needed and confirmed the presence of both Tums and menthol rub on the bedside table. Subsequent observation also revealed a half-full bottle of Rolaids and menthol rub at the bedside while the resident was out of the room. A review of the electronic medical record showed no self-administration assessment had been completed for this resident, and the order summary only listed Tums, not Rolaids. An LPN confirmed that medications should not be left at the bedside without proper assessment and that the resident did not have a self-administration order. The facility's policy requires an interdisciplinary team assessment before allowing self-administration of medications, which was not followed in this case.