Unauthorized Medication Found at Bedside Without Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and only kept at bedside with a physician’s order, as required by facility policy and professional standards. During observation, a resident was found with an Ipratropium Bromide nasal spray on the bedside table, which the resident stated was used for allergies. The resident’s daughter reported she did not know who brought the medication and suggested it may have come from the resident’s belongings from another place. Review of the resident’s physician orders showed no order for Ipratropium Bromide nasal spray. When the surveyor informed an LPN of the medication at the bedside, the LPN acknowledged that medications should not be stored at bedside and should have a physician’s order to be administered. The DON similarly stated that medications should not be at the bedside without an order and that all medications require a physician’s order for administration, and was informed there was no order for the nasal spray. The DON also reported there was no policy available for medication storage, although the facility’s Bedside Medications policy, revised 03/21, states that bedside storage may be allowed for certain forms (such as inhalation) only with a specific physician order. The resident had been admitted with diagnoses including primary osteoarthritis of the right wrist, post-surgical aftercare for genitourinary surgery, muscle weakness, need for assistance with personal care, insomnia, and essential hypertension, but none of the documented orders included the nasal spray found at bedside.
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