Medication Left at Bedside Without Self-Administration Assessment or Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure the interdisciplinary team determined a resident’s ability to safely self-administer medications and to follow facility policy prohibiting medications from being left at the bedside without a physician’s order. Facility policy stated that nurses were personally responsible for every drug they administered, were to remain with the resident until medications were swallowed, and were not to leave medications with residents except with a doctor’s order. A separate self-administration policy required evaluation of residents’ desire and competence to self-medicate, review by the interdisciplinary team, and documentation in the care plan. For the resident involved, there was no documented evidence of a self-medication assessment or a medical order authorizing self-administration. The resident had diagnoses including neurocognitive disorder, Parkinson’s disease, and epilepsy, and was documented as cognitively intact and largely independent in activities of daily living. The care plan documented use of carbidopa-levodopa and directed staff to administer medications as ordered and monitor for side effects. During observation, surveyors found a medication cup at the resident’s bedside containing one whole and one half white pill; the resident stated a nurse had left the medication, was unsure what it was, and was unsure how long it had been there. The LPN later identified the medication as levodopa, admitted they had signed it as administered before the resident took it, and acknowledged they became distracted and left the room before ensuring ingestion, despite the resident having no order to self-medicate. The RN unit manager confirmed that nurses were expected to ensure residents swallowed medications at the time of administration, that no residents on the unit had self-medication orders, and that medications should not be left at the bedside.
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.