Unauthorized Medications Kept at Bedside Without Self-Administration Assessment or Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were stored and administered according to policy for one cognitively intact resident. The resident was admitted with multiple diagnoses including major depressive disorder, anxiety disorder, neuromuscular bladder dysfunction, ventilator dependence, morbid obesity, obstructive sleep apnea, polyneuropathy, chronic diastolic CHF, chronic respiratory failure with hypoxia, and bradycardia. A quarterly MDS showed a BIMS score of 15, indicating intact cognition. Review of the physician’s orders, care plan, and EHR showed no evidence of an order authorizing the resident to self-administer medications and no documented assessment for self-administration, despite facility policy requiring IDT assessment and documentation when a resident participates in self-administration of medications. During an observation in the resident’s room, surveyors noted a bottle of Zinc 50 mg and a bag of Halls cherry-flavored menthol cough drops on the bedside table. The bottle of zinc was labeled with the resident’s name and room number. The resident stated that both items had been at the bedside since admission. There was no evidence in the EHR of any physician order for oral zinc or for cough drops for this resident. The presence of these items at bedside occurred without the required assessment, orders, or care plan entries for self-administration, and without secure storage as required for medications. Interviews with staff confirmed that the zinc and cough drops were considered medications that should not be kept at bedside without a self-administration order. A CNA stated that medications include prescribed and OTC items, including vitamins, and that residents cannot have medications at bedside unless authorized to self-administer; she acknowledged that zinc and cough drops at the bedside should not have been there. An RN similarly stated that medications can be prescribed or OTC and include oral, topical, inhaled, or injected forms, and confirmed there were no orders for zinc or cough drops for this resident. The unit manager and DON both stated that residents may not have medications at bedside unless assessed and authorized for self-administration, with documentation and appropriate storage, which had not occurred for this resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.