Unsupervised Medication Left at Bedside Without Self-Administration Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper medication administration and adherence to its self-administration policy for one resident. During an observation, the resident’s morning medications were found in a pill cup on the bedside table without staff present. The resident stated that he self-administered his medications and that nursing staff often placed his medications at the bedside until he was ready to take them, indicating that this was a routine practice. At the time, these medications were his scheduled morning medications, which he preferred to take later in the morning. A QMA reported that he had placed the medications at the bedside for the resident to take when ready and confirmed that the resident self-administered his medications, but he was unable to locate any provider order authorizing self-administration. Record review showed the resident had multiple diagnoses, including COPD, chronic kidney disease, hepatic encephalopathy, seizures, and congestive heart failure, and an admission MDS indicating he was cognitively intact with a BIMS score of 15/15. However, there was no completed self-administration of medications assessment and no orders for self-administration in the record, despite the facility’s policy requiring a physician order and an assessment to determine the ability to self-administer medications. The DON confirmed there was no evaluation or order for self-administration and stated that nurses should remain with residents until medications are consumed.
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