Medication Storage Deficiency: Unsecured Medication at Bedside
Penalty
Summary
A deficiency occurred when a bottle of Milk of Magnesia, a liquid medication, was found on the nightstand next to a resident's bed. The resident, an older female with osteoarthritis and a history of repeated falls, was cognitively intact but did not have a physician's order to self-administer medication, nor was there documentation in her care plan authorizing self-administration. The medication was not listed in the resident's physician orders, and there was no indication that staff were aware of its presence prior to the surveyor's observation. Interviews revealed that the medication had been brought in by the resident's family without notifying facility staff. The resident stated she kept the medication at her bedside for occasional use, including applying it to her mouth for discomfort. Facility staff, including an LVN, DON, and ADON, confirmed that medications should not be kept at the bedside unless there is a physician's order and an assessment for self-administration. The facility's policy requires unauthorized medications found at the bedside to be turned over to nursing staff.