Unlabeled Nonlegend Medication Found at Bedside Without Physician Order
Summary
A deficiency was identified when a bottle of Pepto-Bismol, a nonlegend medication, was found at the bedside of a patient without a physician's order. The medication was observed on the patient's nightstand, unopened and without a label. The patient stated that her daughter had brought the medication for her to use if needed, and that it had been on her nightstand for some time. Review of the patient's records showed no order for Pepto-Bismol, and the medication was not listed on the Medication Administration Record. The patient had multiple diagnoses, including end stage renal disease, type 2 diabetes mellitus, and congestive heart failure, and required moderate assistance with activities of daily living. During interviews, facility staff, including a Licensed Vocational Nurse and the Assistant Director of Nursing, confirmed that medications should not be left at the bedside without a physician's order and an assessment for self-administration. The facility's policy requires that any medication brought in by family must be given to licensed staff for labeling, verification of an order, and assessment before being left at the bedside. The presence of the medication at the bedside without following these procedures constituted a failure to prevent unauthorized access to medication and to ensure proper medication management as required by facility policy and regulation.
Plan Of Correction
C2000 - Pharmaceutical Services - Labeling & Storage A) IMMEDIATE CORRECTIVE ACTION: On 10/06/2025, the Charge Nurse immediately removed the Pepto-Bismol from the resident's bedside. RN supervisor immediately assessed Patient 7, who is alert and oriented x 4, for any changes of condition and/or adverse effects of having non-prescribed medications at bedside. None were noted. When the RN asked the patient about the medication, she indicated that her daughter brought it for her to use when she needs it. MD and RP were notified. The Charge Nurse obtained an order from the MD for the medication to be given as needed, medication secured in the medication cart, and the RN supervisor explained to the patient about no medications being allowed at bedside until a proper assessment is accomplished. The resident agreed to have the medication stored in the medication cart and to ask the Charge Nurse for it if she ever needed it. The DON completed a one-on-one in-service with LVN 2 regarding policies and procedures for self-administration of medications. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/6/2025, DON, ADON, and DSD immediately rounded the facility to identify any additional medications at residents' bedsides. No additional medications were noted at bedsides. Ongoing daily rounds by the RN supervisor, ADON, DON, and Ambassadors will continue to focus on the presence of medications at bedside. Any presence of medications will be dealt with accordingly. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/29/2025, the Administrator updated the Resident Centered Care Room Rounds Report to ensure room ambassadors are checking resident bedsides for any OTC and/or prescription medications. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: Room ambassadors will provide Room Rounds Reports to DON/Designee upon completion, and audit results will be presented and discussed with the QAPI/QAA committee for the next three months to ensure compliance.
Penalty
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