F0554

D

Medications Left at Bedside Without Self-Administration Assessment or Orders

Ashland, Virginia Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

Facility staff failed to ensure it was clinically appropriate for a resident to self-administer medications when medications were left at the bedside without required assessment or physician orders. During an initial tour, surveyors observed a medicine cup containing seven colored tablets and two oblong white tablets on the overbed table of Resident #7, who was not in the room. Later the same day, during an evening tour, the medicine cup with the seven colored tablets remained on the overbed table, but the two oblong white tablets were no longer present, and the resident was again not in the room. Review of the clinical record showed that the resident had no active order for the medication found at the bedside and no order for self-administration of medications.

Resident #7 had been admitted with diagnoses including alcoholic cirrhosis of the liver with ascites and gastro-esophageal reflux disease without esophagitis, and had a BIMS score of 13/15, indicating mild cognitive impairment. An interview with an LPN revealed that the resident had requested Tylenol after breakfast and was given two 500 mg Tylenol tablets at approximately 10:00 a.m.; the LPN stated the resident must have put them down instead of taking them as he said he would. The LPN also stated that medications should never be left at the bedside without a self-administration assessment and physician orders, and that no residents on the unit had such assessments or orders. Review of the facility’s Self-Administration of Medication and Treatments Policy showed that residents have the right to self-administer medications only if the interdisciplinary team has determined it is clinically appropriate and safe, which had not been done for this resident.