Unsecured Bedside Medications Left With Resident Despite No Self-Administration Order
Penalty
Summary
The deficiency involves the facility’s failure to secure medications and prevent unauthorized self-administration for a resident who had explicit physician orders prohibiting self-administration. The resident was admitted on a specified date and had a physician’s order dated 6/25/2025 stating that he may not administer his own medications, as well as an order for staff to monitor his swallowing during medication passes and document any coughing, pain, or difficulty swallowing. During an observation on 2/24/2026 at 2:50 PM, surveyors found a medication cup containing seven pills on the resident’s bedside table while the assigned nurse was no longer passing medications on the hallway. The resident stated he would take the medications in the cup when they let him out of the facility. At 2:55 PM the same day, the assigned nurse confirmed that the cup contained the resident’s lunch medications, which she had given him at approximately 1:30 PM, and acknowledged that he usually took them when handed to him. When the nurse asked the resident to take the medications, he refused, repeating that he would take them when he got up out of there, and did not take them at that time. The nurse then removed the medication cup and later stated she had trusted the resident would take the medications and recognized this as a lapse in judgment, acknowledging she knew he was not to have medications left at the bedside and that she was required to monitor and document his swallowing. The physician later stated he did not recall the no self-administration order but agreed that if such an order existed, the resident probably should not self-administer, and he expected staff to follow physician orders. The DON confirmed that only one resident in the facility had an order to self-administer medications and that all others, including this resident, had orders that they may not self-administer medications.
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.