Failure to Ensure Proper Medication Storage and Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly labeled and stored, as required by professional standards and facility policy. During observations, two residents were found to have eye drop medications at their bedside without provider orders or documented assessments for self-administration. In one case, a resident with a history of right femur fracture, anemia, and hypotension was observed with a container of Refresh lubricant eye drops on her bedside table. The resident reported bringing the eye drops from home and using them twice daily, but there was no evidence of a provider order or an assessment for self-administration at the time of observation. A subsequent physician order and documentation for self-administration were only obtained after the medication was discovered at the bedside. In another instance, a resident with dementia, muscle weakness, and a history of head injury was found with two types of eye drops on her bedside table. The resident stated that her mother had brought the eye drops about a month prior, but she had not used them. There was no evidence in the clinical record of a provider order, a self-administration assessment, or an interdisciplinary team meeting regarding medication self-administration for this resident. Staff interviews confirmed that the medications were present at the bedside and that the resident had not been assessed for self-administration, as required by facility policy. Facility policy requires that all medications be administered as ordered and that residents are assessed for the ability to self-administer medications, with proper documentation and provider orders. The policy also specifies that bedside medication storage is only permitted under certain conditions and that unauthorized medications found at the bedside must be reported and removed. In both cases, these procedures were not followed, resulting in medications being left at the bedside without appropriate authorization or assessment.