F0761

D

Medications Left at Bedside Without Orders or Self-Administration Assessment

Prescott, Arizona Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that medications were not left at the bedside for two residents without a provider order and without completion of a self-administration assessment, contrary to facility policy and professional standards. For one resident with pneumonia, atrial fibrillation, hypertension, and a need for assistance with personal care, orders were in place for Metoprolol Tartrate 12.5 mg twice daily for high blood pressure and Saccharomyces boulardii 250 mg twice daily as a probiotic. The resident’s BIMS score indicated that she was cognitively intact and she was independent with eating and oral hygiene, but there was no documentation in the clinical record of an assessment for self-administration or a physician order allowing medications to be left at the bedside. The MAR showed that both medications were administered at the scheduled morning time.

During an observation later that same morning, the resident’s medications were found left on her bedside table. As the resident attempted to take the pills, she knocked over the medicine cup, causing both pills to spill. She reported that she was able to retrieve the white probiotic capsule but could not find the small pill for her irregular heart rate, and explained that she had not taken the medications immediately when the nurse brought them because she was on the phone with her brother. Over the next several minutes, a CNA and an LNA entered the room, and the resident informed them that the medication cup had flipped; both staff members indicated they would inform the nurse. When an LPN entered the room, the resident again reported that the medication cup had gone flying. The LPN stated she would provide another pill, then returned with Metoprolol 12.5 mg and also reported finding the other pill in the trash can. While the LPN was present, the resident dropped another pill from her mouth, and the LPN left again to obtain another dose. Interviews with the LPN charge nurse and the DON confirmed that facility expectations were that nurses observe residents swallow medications and do not leave medications at the bedside unless there is a specific order and a completed self-administration assessment, which were not present for this resident.

For a second resident with acute posthemorrhagic anemia, atrial fibrillation, GERD without esophagitis, and alcohol dependence, the care plan included a focus on GERD related to medication use, with interventions to give medications as ordered and monitor side effects and effectiveness. The resident’s BIMS score indicated that she was cognitively intact. A physician order directed that Calcium Carbonate (Tums) 500 mg be given by mouth before meals for GERD, and the MAR showed that the medication was documented as administered as ordered. However, there was no evidence in the clinical record from admission through the date of observation that the resident had been assessed for self-administration of medications, and there was no physician order authorizing self-administration of Tums.

During an observation, the resident was seen in bed with a glass of water and a clear cup containing three pink circular pills at the bedside. The resident identified the pills as Tums that she takes for stomach issues and stated that nurses leave them there for her to take when needed. An LPN confirmed that the pills were Tums and acknowledged that they were usually left on the bedside table for the resident to take independently, and that she had left them there that day even though the resident did not have a self-administration assessment and medications should not be left at the bedside. A CNA and an RN both stated that no medications, including Tums, should be left at the bedside without a physician order, and the RN noted that if there were an order for self-administration, the medication should be stored in an appropriate container. The DON similarly stated that no medication should be left at the bedside without a physician order for self-administration and that leaving medications such as Tums at the bedside could pose a risk to the resident or others. Facility policies on Medication Access and Storage and Self-Administration of Medications required that drugs be stored in locked compartments accessible only to authorized personnel and that self-administration be based on an interdisciplinary assessment and provider order, conditions that were not met in these instances.