Failure to Assess and Obtain Orders for Resident Self-Administration of Medications at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders for medications to be kept at the bedside and to complete required self-administration of medication assessments and care plans for three residents. One resident with emphysema and chronic bronchitis had multiple prescribed respiratory inhalers, nasal spray, and topical hydrocortisone ointment stored on the bedside table. The resident reported that these medications were always kept in the room and that no one at the facility had instructed her on their use. Review of the physician order sheet confirmed active orders for all of these medications but no orders authorizing them to be kept at the bedside. The electronic medical record contained no self-administration of medication assessment form, and there was no care plan addressing self-administration. A second resident had ordered ophthalmic drops and an over-the-counter saline nasal spray kept in the room and stated that these medications were always kept there and that the nurse had not taught him how to use them, although he had used them for a long time. The physician order sheet contained an order for the eye drops but no order for the nasal spray or for bedside storage of either medication, and there was no self-administration assessment or related care plan in the record. A third resident kept lidocaine patches, saline nasal spray, nebulization solution vials, and lubricant eye drops on the nightstand, stating they were kept there for easier access and that no assistance or teaching was needed. The physician order sheet contained orders for these medications but no authorization for bedside storage, and the record lacked a self-administration assessment and care plan. The facility’s own policy required a licensed nurse to complete a self-administration evaluation, IDT documentation and care planning, periodic reevaluation, and a physician order specifying which medications could be kept at the bedside, none of which were completed for these residents. The DON confirmed that medications brought from home should be locked and that staff should contact family and the physician and complete an assessment before allowing bedside self-administration.
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