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Based on a review of facility policies and procedures, medical record, and staff interviews, it was determined that the facility failed to provide a safe environment when one patient (P) (P#1) of four (P#1, P#2, P#3, and P#4) sampled patients verbalized self-administering a medication while under the care of the facility. The facility failed to properly initiate and monitor self-administration medication procedures which resulted in P#1 self-administering a medication and continuing to keep the medication at the bedside potentiating for adverse effects.


Findings Included:


A review of the facility's policy titled "Non-formulary Medications and Medications/Devices from Home," policy #MU-07-01, last revised 6/19/24, revealed that the purpose of the policy was to define a safe process for handling non-Formulary and patients' home medications.

Continued review revealed, Procedure, Medications or Medication Devices Brought into the Facility from an Outside Source, this includes patients' home medication and any related medication devices brought into the facility for use by a patient while in the hospital.

2.7. Send the medication to the inpatient pharmacy for identification and labeling.
2.8. Keep the patient's own medications securely stored in the medication room or protected bin.

Continued review revealed, Storage of Patient Home Medications:
4.1. Request the patient completed a "Release of Liability for Storage of Home Medications".
4.2. List each medication: medication name, strength, and quantity.
4.3. Place the "Release of Liability for Storage of Home Medications" form (white copy) in the consent section of the patient's chart.
4.4. Take the patient's medications and the yellow copy of the form to the main pharmacy.
4.5. Give the pink copy to the patient.

Continued review revealed, Patient/Family Member Medication Self-Administration:
5.1. Assess patient knowledge of medication and cognitive and physical ability to perform medication self-administration.
5.2. Obtain physician order authorizing patient to self-administer medication.
5.3. Provide authorized self-administered medication to patient at scheduled time or per patient request as appropriate.


A review of an "Infectious Disease Consultation Note" dated 7/11/25 at 1:43 p.m. by a physician revealed that P#1 was complaining of an allergic reaction to adhesives and is treating herself with Benadryl.


During a telephone interview on 7/22/25 at 9:32 a.m., Registered Nurse (RN) RN CC recalled that prior to her assuming care for P#1, P#1 was self-medicating with Benadryl. RN CC recalled that the medication bottle of Benadryl was present on the patient's table and that RN CC told P#1 that she would get a physician to profile Benadryl for her because she (RN CC) did not want P#1 to continue self-medicating for safety reasons. RN CC recalled that she was able to put up P#1's Benadryl medication bottle away from her reach and tried to get P#1 to put it in the hospital safe, but P#1 refused the latter. RN CC said that a physician did not profile Benadryl for P#1. RN CC recalled that a physician saw the medication at the patient's bedside but did not remove it or ask any staff member to remove it. RN CC said that no escalation was done.


During an interview on 7/22/25 at 1:25 p.m. in the conference room, Assistant Nurse Manager (ANM) DD said that when a patient brings in their own medication, the staff RN is expected to collect the medication, document it, and give it back to family members. ANM DD said that if the medication is a special formulary medication and the patient wishes to use it, then staff must take it down to the pharmacy for review and labeling, notify the provider for an order, and then staff may use it as ordered. ANM DD said that if staff find a patient using their own medication, then staff are expected to stop the patient, educate them on the risk, and escalate it up the chain of command. ANM DD said that she would get a physician involved to see if it is a medication they can profile and work with the patient because there are so many medication interactions and they do not want the patient to potentially get hurt.