Failure to Assess Resident Before Leaving Medications at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for the ability to safely self-administer medications before leaving medications at the bedside unsupervised. The resident had a diagnosis of hemiplegia affecting the left nondominant side and an Annual MDS showing a BIMS score of 15, indicating intact cognition. However, the resident’s EMR contained no Self-Administration of Medications assessment, and the Baseline Care Plan did not address self-medication. Despite this lack of assessment and care plan direction, staff practice resulted in medications being left in the resident’s room. During observation, the resident was noted to have a pill cup with two pills on the bedside table and stated she had a question about what the pills were. When a licensed nurse entered, the resident asked what the pills were; the nurse stated one looked like Tylenol but would need to check on the other pill and then said she needed to ask the CMA who had placed and left the medications in the room. The nurse removed the pills to consult the CMA. The resident reported she had never been assessed to self-administer medications to her recollection. When interviewed, administrative staff stated that residents appropriate for self-administration would be identified in the care plan after provider notification and an order, and also stated that medications should not be left at the bedside, which contrasted with the observed practice and the facility’s own Medication Administration Policy referencing a Self-Administration Policy and Procedure.
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