Unauthorized Medications Left at Bedside Without Self-Administration Orders
Penalty
Summary
Surveyors identified a deficiency related to medication storage and self-administration when a resident was found with medications left at the bedside without authorization. The resident, who had a history of Type 2 Diabetes Mellitus with diabetic neuropathy, COPD, dementia, and major depressive disorder, had a quarterly MDS with a BIMS score of 13, indicating cognitive intactness. Review of the resident’s care plan, physician’s orders, and electronic medical record showed no care plan, orders, or interdisciplinary team documentation authorizing self-administration of medications. Despite this, during a room observation, two medications—Fluticasone Propionate Suspension 50 mcg/act and Bacitracin Zinc 400 units—were observed at the resident’s bedside. During interviews, the resident confirmed that one medication was used every other day on her toes and that the other was a nasal spray used occasionally. A subsequent observation with the DON again revealed the two medications at the bedside. The DON confirmed that residents without self-administration orders should not have medications left out and acknowledged that this situation did not meet facility expectations. Review of facility policies showed that self-administration requires an interdisciplinary assessment and documentation in the chart, and that all drugs and biologicals must be stored in locked compartments accessible only to authorized personnel, which was not followed in this instance.
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