Medications Left at Bedside Without Self-Administration Orders or Assessments
Penalty
Summary
Staff failed to ensure that medications were administered in accordance with facility policy and professional standards for two residents. In one instance, a resident's family reported that medications were often left at the bedside, despite the resident being unable to self-administer medications safely. Review of the resident's record confirmed there was no documented evaluation or physician order permitting self-administration of medications. The resident had a diagnosis of end stage renal disease. In another case, medications were observed at the bedside of a second resident, who stated that an LPN had left the medications for him to take with lunch, which he would not receive until later. The LPN confirmed that no residents were permitted to self-administer medications and acknowledged that medications should not be left at the bedside. The resident's record showed no physician order or evaluation for self-administration, and the care plan specified that a nurse was to administer medications. The resident was cognitively intact and had diagnoses of end stage renal disease and type 2 diabetes mellitus. Facility policy required a self-administration assessment and physician order for any resident self-administering medications, which was not followed in these cases.