Medication Left at Bedside Without Self-Administration Order
Penalty
Summary
Surveyors observed that a clear plastic medicine cup containing a white oblong pill was left on a resident's bedside table, and the DON later removed it, stating it should not have been left there. The resident's clinical record showed diagnoses including type 2 diabetes mellitus with diabetic neuropathy, chronic pain, bilateral knee pain, abnormal posture, and muscle weakness. The record contained a physician's order for hydrocodone-acetaminophen 7.5/325 mg every four hours and a pain management care plan directing staff to administer medications as ordered. However, there was no physician's order, self-medication administration assessment, or care plan authorizing the resident to self-administer medications. Multiple staff interviews confirmed that medications were not to be left at the bedside unless there was an order for self-administration and that staff were required to observe residents consuming all medications before leaving the room. The ADON, DON, and several RNs each stated that the resident did not have an order to self-administer medications and that the pill cup should not have been left in the room. Facility policies on General Dose Preparation and Medication Administration required staff to observe residents' consumption of medications, and the Self-Administration of Medications policy required a physician order specifying a resident's ability to self-administer medications. The presence of the unattended pill at the bedside without the required order or assessment constituted the deficiency.
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