Failure to Assess and Obtain Order for Self-Administration Before Leaving Medication at Bedside
Penalty
Summary
The deficiency involves a nurse leaving a medication at a cognitively impaired resident's bedside without an assessment or physician order for self-administration. During observation, an LPN prepared the resident's medications, including 17 grams of Miralax dissolved in water, and brought them to the resident's room. The resident took his pills and only a few sips of the Miralax, then placed the cup on the bedside table. The LPN stated she would return later to assist the resident with finishing the Miralax but left the room and returned to the nurse's station, leaving the Miralax in the resident's room and not remaining to ensure the medication was taken. Record review showed the resident had diagnoses including hypertension, generalized anxiety disorder, and major depressive disorder, and the most recent Quarterly MDS indicated the resident was cognitively impaired. There was no documentation of any physician's orders authorizing self-administration of medications and no assessment for self-administration in the record. The facility's policy on self-administration of medications required an interdisciplinary team assessment of the resident's competence and a physician order specifying the resident's ability to self-administer and which medications were included, but these steps had not been completed for this resident when the medication was left at the bedside.
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