Failure to Assess and Secure Self-Administered Medications
Penalty
Summary
A resident with a history of stroke resulting in left-sided hemiparesis and hemiplegia was observed to have unsecured medications, including Tylenol and Melatonin, on their bedside nightstand on multiple occasions. The resident had no significant cognitive impairment and had a physician's order allowing these medications to be kept at the bedside for self-administration. However, there was no documented assessment completed to determine the resident's ability to safely self-administer these medications, as required by facility policy. Interviews with staff revealed that the process for assessing the resident's capability to self-administer medications was not followed. The resident was not provided with a lockbox to secure the medications, and staff were unaware that the medications were being kept at the bedside. The lack of assessment and secure storage was confirmed by multiple staff members, including the LPN Care Manager and the Director of Nursing Services, who acknowledged that the required procedures were missed after the physician's order was obtained.