Medication Storage and Administration Protocol Not Followed
Penalty
Summary
A deficiency occurred when a registered nurse (RN) left a resident's prescribed eye drop medication at the bedside, allowing the resident to access and potentially self-administer the medication unsupervised. The resident, a male with dementia and a cataract diagnosis, had a moderate cognitive impairment as indicated by a BIMS score of 11 out of 15. The medication, Prolensa Ophthalmic Solution, was ordered to be administered once daily for cataract surgery. During an interview and observation, the RN acknowledged that the medication should not have been left at the bedside, even though the resident might be capable of self-administration. Further investigation revealed that there was no documentation or assessment indicating that the resident was authorized or capable of self-administering his medications. The Director of Nursing (DON) and Administrator were unaware of any such assessment or care plan. Facility policy requires that only licensed or legally authorized personnel administer medications and that medications are not left with residents unless proper assessment and documentation are in place. This lapse in medication storage and administration protocol led to the cited deficiency.