Medications Left at Bedside Without Self-Administration Order
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards when medications were left at the bedside for one resident. The facility’s “Oral Medication Administration Procedure” policy states that staff must administer oral medications in an organized and safe manner, remain with the resident while the medication is swallowed, and never leave medication in a resident’s room without an order for self-administration. Review of the resident’s orders showed there was no order for self-administration of medication. The resident involved had diagnoses including post hemorrhagic anemia, gastrointestinal hemorrhage, irritable bowel syndrome, and osteoarthritis, and had a BIMS score of 15/15, indicating no cognitive impairment. The baseline care plan documented decreased ability to perform ADLs/self-care related to debility/generalized weakness. During observation, two white tablets were found in a medication cup on the resident’s bedside table. An LPN confirmed the medications should not have been left in the room and that the resident did not have an order to self-administer. The resident stated that a nurse had brought the medications the previous night and that she was saving them to use when needed, identifying them as Imodium. The DON stated that nurses are not to leave medications at the bedside and should remain with the resident to ensure medications are swallowed safely, and that anyone could take medications left at the bedside.
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