Medications Left at Bedside Without Order or Safety Assessment
Penalty
Summary
The deficiency involves staff leaving medications at a resident's bedside for unsupervised self-administration without a physician order or completed safety assessment. During an observation, a resident with neuromuscular spasticity of both upper extremities, weak vocal quality, slowed speech, and generalized neuromuscular weakness was seen lying in a recliner with seven assorted capsules in a medicine cup on a table within reach. The medications were accessible without supervision. A staff member later stated she had entered the resident's room earlier and left the medications at the bedside while the resident was in the shower, and acknowledged the resident probably did not have a physician's order for self-administration of medications. Further review of the resident's electronic health record showed diagnoses of oropharyngeal dysphagia, dysarthria, anarthria, and conversion disorder with motor symptoms. The record contained no self-administration safety assessment or physician order authorizing self-administration of medications. A speech therapy note indicated the resident was permitted to have bread and was on a regular diet with a preference for rye bread, but there were no additional speech therapy notes or swallow evaluations documenting the resident's ability to safely swallow or self-administer medications. The facility did not provide any documentation of a medication self-administration safety assessment, speech therapy evaluation supporting safe self-administration, or a physician order for self-administration by the end of the survey, and the failure was noted to place the resident at risk for choking, aspiration, and medication errors.
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