Unauthorized Bedside Storage of Medications Without Physician Order or Assessment
Penalty
Summary
A deficiency occurred when a resident was found to have over-the-counter medications, including Luden's cough drops, Neosporin ointment, and Equate hydrocortisone cream, stored at the bedside without a physician's order or care plan authorizing self-administration. The resident's medical record did not contain any orders for these medications, nor was there documentation of a self-administration medication assessment or a care plan addressing the storage or self-administration of medications. Multiple observations over several days confirmed that the medications remained accessible on the resident's bedside table while the resident was not present in the room and the door was open. Interviews with the resident revealed that he did not inform nursing staff about possessing the medications, stating he was capable of managing them himself. The responsible party for the resident admitted to bringing the medications into the facility and was unaware of the requirement to notify staff about over-the-counter medications. Nursing staff and the DON confirmed that facility policy requires a physician's order and a completed self-administration assessment before a resident may keep medications at the bedside, and that unauthorized medications should not be left in resident rooms. Review of facility policy indicated that all medications found at the bedside without authorization must be reported and returned to the responsible party, and that the care plan must reflect any arrangements for self-administration and storage. In this case, the facility failed to follow its own policy and federal regulations regarding medication storage, labeling, and resident self-administration, resulting in unauthorized medications being accessible in a resident's room.