Failure to Remove Discontinued Medications and Prevent Improper Storage
Penalty
Summary
A deficiency occurred when a resident was found storing discontinued medications at their bedside, which had not been properly removed by nursing staff. The resident, who was cognitively intact and had diagnoses including alcohol dependence with withdrawal, chronic obstructive pulmonary edema, hypertension, anxiety disorder, and major depressive disorder, reported that a nurse had attempted to administer a discontinued medication. The resident identified the error, did not take the medication, but kept it in a medication cup on the bedside table. The resident also had another pill in the cup that had been discontinued months prior. There was no care plan or intervention documented that allowed the resident to self-administer medications. Interviews with the LPN involved revealed that she had mistakenly given the resident a discontinued medication, and was unaware of the presence of the other discontinued pill. The DON confirmed that one of the pills had been discontinued recently and the other several months ago. Facility policy requires that only licensed staff administer medications and that residents may only self-administer if specifically authorized by the care team and physician, which was not the case for this resident. The failure to remove discontinued medications and prevent their storage at the bedside, as well as the lack of proper documentation for self-administration, led to the deficiency.