Unauthorized Self-Administration and Bedside Storage of Ophthalmic Medications
Penalty
Summary
Facility staff failed to follow its policy on resident self-administration of medications by allowing a resident to keep and self-administer multiple ophthalmic medications at the bedside without the required assessment or physician order. The facility’s policy, revised 8/1/25, states that residents may only self-administer medications after an interdisciplinary team determines which medications can be safely self-administered, with consideration of the resident’s physical and cognitive abilities, understanding of medication instructions, and ability to store medications safely. The policy also requires documentation of the self-administration assessment in the medical record, a physician order authorizing self-administration and bedside storage, and staff reporting of any unauthorized medications found at the bedside. Record review for one resident showed active physician orders for Ofloxacin 0.3% ophthalmic solution, Ketorolac Tromethamine 0.5% solution, and Prednisolone acetate 1% ophthalmic suspension, each ordered four times daily for cataract-related treatment, but no orders authorizing self-administration or bedside storage of these eye drops and no completed self-administration assessment in the medical record. On multiple observations, surveyors saw three eye drop bottles (Ofloxacin, Ketorolac, and Prednisolone) on the resident’s bedside table, and the resident stated that they administered the eye medications themself. In interviews, an RN and the DON confirmed that facility practice requires a management-conducted self-administration assessment and a physician order permitting self-administration and bedside storage, which were not present for this resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.