Unauthorized Medication Storage at Bedside Without Physician Order
Penalty
Summary
A deficiency occurred when a tube of diclofenac sodium 1% topical gel, which had expired, was found stored at the bedside of a resident who lacked the capacity to understand and make decisions. The medication was not authorized for self-administration, and there was no physician's order, care plan, or documentation permitting the resident to store or self-administer the medication. The facility's policy required that any medications found at the bedside without authorization for self-administration be turned over to the nurse in charge, but this procedure was not followed in this instance. The resident's medical record indicated that the resident did not wish to self-administer medications and had no assessment or order allowing for self-administration. Facility staff, including an RN and the DON, confirmed that the medication should not have been left at the bedside and that it may have been brought in by the resident's family. The medication was accessible in the resident's room, and staff verified that there was no documentation or physician's order supporting its presence or use at the bedside.