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Based on record reviews, interviews, and policy review, nursing staff failed to adhere to the facility's policy to only leave medications at the bedside if there was a physician order for self-administration of medication or allowing a family member to administer medications. This deficient practice affected one of five (Patient (P) 1) records reviewed for medication. The failure to follow hospital policy for medication administration has the potential to place all patients in the facility at risk for adverse medication events.

Findings Include:

Review of the hospital's policy titled, "Self-Administration of Medications," effective date, 06/09/17, stated, "Self-administration of medication by hospitalized patients shall only be permitted on a specific documented order by the authorized prescribing practitioner."

Review of P1's "Physician Orders" revealed that there was no documentation of a physician's order for self-administration of medication or allowing a family member to administer P1's medications.

During an interview on 05/11/23 at 10:00 AM, Registered Nurse 2 (RN2) explained that when he/she went in to give P1's medication, the grandchild did not want P1 disturbed and stated, "I'm a nurse, leave it with me and I will give it to him/her." RN2 stated that I was trying to keep the peace. RN2 further explained that he/she left the medications at the bedside with the family member and did not witness the medications given to the patient.

During the interview on 05/11/23 at 10:00 AM, RN2, the Director of Quality (DQ) and RN6 confirmed that a physician's order was not obtained for the self-administration of P1s medications.