Failure to Ensure Safe Medication Administration and Storage at Bedside
Penalty
Summary
A deficiency occurred when a resident was found with an albuterol inhaler and artificial eye gel drops at their bedside without the required physician orders or proper assessment documentation. The facility's policies require that medications be administered according to provider orders and that residents must be assessed and have a physician order to self-administer or keep medications at the bedside. The resident, who had diagnoses including heart failure, COPD, type 2 diabetes, and pneumonitis, was alert, oriented, and able to make their own medical decisions. However, the only self-administration assessment on file pertained to nebulizer use, and there were no orders for the resident to self-administer the inhaler or eye drops, nor to store these medications at the bedside. Surveyors observed the medications at the bedside and confirmed with both the resident and staff that the resident used the inhaler for shortness of breath and the spouse administered the eye drops. Nursing staff and the Director of Nursing acknowledged that the medications should not have been at the bedside without appropriate orders and assessment. The lack of proper documentation and orders for self-administration and bedside storage of these medications constituted a failure to provide pharmaceutical services in accordance with facility policy and regulatory requirements.