Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
A deficiency occurred when a resident was not assessed for clinical appropriateness to self-administer medications, yet was left with a cup containing six medication pills on the overbed table while sleeping. The resident's medical record did not include a completed self-administration assessment, and the quarterly MDS indicated the resident was cognitively intact. Despite this, the facility's policy requires specific authorization and assessment before allowing self-administration of medications. The LPN confirmed leaving the medications at the bedside while the resident was asleep, and the resident later confirmed self-administering the medications after returning from therapy, expressing surprise at finding the medications left out. Observations showed the medication cup remained on the overbed table for several hours, even when the resident was not present in the room. The MAR indicated the medications were documented as administered at the scheduled time, although the resident did not take them until much later. The DON confirmed that medications should not be left at the bedside without proper assessment and authorization. No explanation was provided for the failure to ensure the resident was clinically appropriate for self-administration of medications.