F0761

D

Medication Left at Bedside Without Complete Order or Self-Administration Assessment

Mesa, Arizona Survey Completed on 12-16-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that medications were properly ordered, documented, and stored, and that a resident was appropriately assessed and care planned for self-administration of medication. A resident with dementia, OSA, depression, heart failure, and chronic kidney disease was admitted with an MDS BIMS score of 14, indicating cognitive intactness. The resident’s care plans addressed risks related to impaired cognitive function/dementia and psychosocial well-being, including monitoring for changes in cognition and side effects of psychotropic medications, but there was no care plan addressing self-administration of medications.

On the morning of December 14, 2025, the resident was observed lying in bed with a medication cup on the bedside table containing a small rectangular pink pill. An LPN identified the pill as half a tablet that looked like Benadryl. When asked, the resident told the nurse not to take her Benadryl, and the LPN removed the cup from the bedside. The LPN then checked the electronic clinical record and did not find an order for Benadryl. The LPN informed the RN assigned to the resident, who stated he had not left the medication and was not aware of any Benadryl order. The RN disposed of the pill in the sharps container and stated he would notify the provider about the Benadryl.

Review of the MAR for December 2025 showed that an order for Diphenhydramine HCl 25 mg by mouth every 24 hours as needed for itching at bedtime was transcribed on December 14, 2025 at 9:48 AM and discontinued the same day at 1:21 PM, with a new order for 0.5 tablet every 24 hours as needed at bedtime entered at 1:21 PM. Interviews with multiple LPNs confirmed that their usual practice is to verify a provider order before administering any medication, to transcribe the order into the electronic record, to document administration on the MAR, and not to leave medications at the bedside unless there is a self-administration order and assessment of the resident’s capacity. They stated that leaving medication at the bedside is against facility policy and could result in issues such as double dosing or access by other residents.

The DON stated that the expectation for medication administration is to have provider orders and to administer and document medications according to those orders, with staff remaining with the resident until medications are swallowed. She reported being aware of the Benadryl issue and described a process for self-administration that requires assessment of competency and a provider order. The DON indicated that an order for Benadryl had been obtained via text message on a staff/provider work cellphone on a Saturday evening, that the nurse administered the medication, and that the resident bit the tablet in half and requested to save the other half. Facility documentation of the text message showed a provider response of “Yeah prn” to a request for Benadryl to sleep, but the message lacked a date stamp, dose, frequency, time, and route. There was no corresponding documentation in the electronic record or MAR that an order for Benadryl to sleep as needed had been received or that the medication had been administered at that time. Facility policies required that no medication be administered without a written, dated, and signed order including name and strength of the drug, dosage, frequency, route, and reason, that orders be recorded and transcribed into the eMAR, and that staff remain with the resident until medications are swallowed. The presence of Benadryl at the bedside without a documented, complete order and without a self-administration assessment and care plan constituted the deficient practice, which the report states could place the resident’s safety at risk.