Failure to Secure Topical Medication and Assess for Self-Administration
Penalty
Summary
A deficiency occurred when a topical pain medication, Diclofenac Sodium, was left in a resident's bedside drawer without proper assessment for self-administration. The resident, who had a history of malignant neoplasm of the rectum and hypotension, was cognitively intact but required supervision for activities of daily living. The medication was ordered to be applied topically as needed for pain, and records showed it was last administered early in the morning. During an observation later that day, two medication cups containing the cream were found above the resident's bedside drawer. Staff present were unaware of who had left the medication there. Further review revealed that there was no documented assessment to determine if the resident was capable of safely self-administering the medication. Facility policy required an interdisciplinary team assessment before allowing self-administration, but this had not been completed. Staff interviews confirmed that the medication should not have been left at the bedside, as it could be accessed by other residents, and that the required assessment for self-administration was missing.