Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure the resident environment was free from potential accident hazards, as evidenced by the presence of medications left unattended at the bedside tables of two residents. The facility's policy on 'Self-Administration of Medications' requires that residents be assessed and deemed safe to self-administer medications, with documentation in their medical records and care plans. However, there was no documented evidence that the two residents involved were assessed or deemed safe to self-administer their medications. During observations, one resident was found with a white tablet on their bedside table while eating breakfast, and another resident had five different colored pills on their bedside table while talking on the phone. The Director of Nursing confirmed that these medications should not have been left at the bedside, as licensed nurses are responsible for administering medications. This oversight was acknowledged as an accident hazard, and the facility failed to maintain a safe environment by allowing medications to be accessible to residents without proper assessment and documentation.
Plan Of Correction
Step 1: Medications were administered by nursing. Step 2: To identify other areas for potential concern, DON/designee quality monitored resident rooms to ensure medications were not left at bedside. Negative findings addressed. Step 3: To prevent this from recurring, DON/designee educated licensed nursing staff on the Facility's medication administration policy. Step 4: To monitor and maintain ongoing compliance, DON/designee quality monitored resident rooms for medications at bedside 5x weekly x 4 weeks then 1x weekly x 4 weeks. Step 5: Findings will be forwarded to QA Committee for further review/recommendations.