Unsecured Phosphate Binder Tablets Left at Bedside Without Self‑Administration Authorization
Penalty
Summary
Surveyors identified a deficiency in medication storage and control when two orangish-brown, disk-like Velphoro (sucroferric oxyhydroxide) tablets were observed in a disposable plastic cup on Resident #4's bedside table. Resident #4, a male with end stage renal disease and dependence on renal dialysis, stated he had just returned from dialysis and that the pills were his phosphate binders given to him that morning. He reported that he chews those binders and that staff watch him take his other medications. At the time of the observation, the Velphoro tablets were not secured in a locked compartment, and there was no documentation that he was authorized to self-administer medications. Record review showed an active order for Velphoro 500 mg chewable tablets, two tablets by mouth with meals for end stage renal disease, with no order permitting self-medication. A Self Medication Program Assessment dated earlier indicated the resident was fully capable in understanding and managing medications, but the care plan documented impaired cognitive function/dementia with a BIMS score of 8.0 and included no focus or intervention for self-medication. The quarterly MDS, however, reflected a BIMS score of 15.0, indicating cognitive intactness, creating inconsistency between assessments and the care plan regarding his cognitive status and self-medication capability. Interviews with staff further clarified that facility practice and policy required medications to be administered by authorized personnel and that staff were to observe residents taking medications, with no medications to be left at the bedside. The MA interviewed stated she had not yet administered the resident’s medications that morning and that staff were supposed to watch residents take their medications. The RN stated phosphate binders were supposed to be watched by staff when administered and swallowed. The DON and Administrator both confirmed that residents were only allowed to self-administer medications following an assessment, physician authorization, and care plan documentation, and that, to their knowledge, no residents were currently permitted to self-administer. Despite these policies, Resident #4 had Velphoro tablets left at his bedside, accessible and not under staff observation, constituting the cited deficiency in secure medication storage and control of access to medications.
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