Medication Safety Lapse for Resident
Penalty
Summary
The facility failed to maintain a safe environment for Resident R213 by leaving medication unattended on the resident's over-bed table on two separate occasions. During an initial tour, a pill was observed in a dose cup on the resident's table, which the resident refused to take due to concerns about increased urination. The following day, the same situation was observed, and the nurse, Employee E7, discarded the pill after the resident again refused it, citing the same reason. The nurse reported to the unit manager that the resident must have spit the pill out after initially taking it. Resident R213 was admitted with a diagnosis of non-ST-elevation myocardial infarction and was prescribed a regimen that included potassium chloride and a diuretic, among other medications. The unattended medication posed a risk as it could have been ingested by another resident, compromising the safety of the environment. The facility's administration confirmed that the medication should not have been left on the over-bed table, acknowledging the lapse in providing a safe environment for residents.
Plan Of Correction
The medication left on resident R213's over bed table was removed. A house-wide audit was completed to ensure that each resident's environment was safe related to medication being left on the residents' over bed table. Licensed staff will be in-serviced on ensuring that a safe environment is maintained related to medication being left on residents' over bed tables. The Director of Nursing/Designee will conduct a random audit of 5 residents' environments to ensure that a safe environment is maintained related to medication being left on an over bed table. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.