Unlabeled Bedside Medications and Lack of Self-Administration Assessments
Penalty
Summary
The facility failed to ensure that medications were not left unattended at residents’ bedsides, that all medications had corresponding physician orders and pharmacy labels, and that required self-administration assessments were completed. One resident admitted with diabetes mellitus and COPD, who had documented capacity to make medical decisions and no memory loss, kept a bottle of eye drops brought from home on his nightstand. The bottle, labeled only with the manufacturer’s label “Colirio Oftal-mycin,” had no pharmacy label, and there was no physician’s order or self-administration assessment for this medication. A second resident with diabetes, kidney disease requiring dialysis, and major depressive disorder, who had capacity to make decisions but required maximum assistance with ADLs, kept a container of Vicks VapoRub on the over-bed table without a pharmacy label, physician’s order, or self-administration assessment. A third resident with COPD and diabetes, independent in all ADLs and with capacity to make medical decisions, kept a home Albuterol rescue inhaler on the nightstand without a pharmacy label, physician’s order, or self-administration assessment. The DON stated she was not aware these residents had medications at the bedside and confirmed that, per facility policy, residents should not have medications for self-administration without an assessment, a physician’s order, and appropriate labeling, and that these situations placed the residents at risk for medication errors and misuse.
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