Medications Left Unattended and Administered Without Orders
Penalty
Summary
The facility failed to ensure that residents consumed their medications as prescribed and according to facility policy. Multiple residents were observed with medication cups containing their scheduled morning medications left at their bedsides or on tables, with no staff present to verify ingestion. In several cases, residents had not yet taken their medications, were unsure of the contents, or were handling the medications themselves. The facility's policy requires staff to observe residents consuming medications and prohibits leaving medications unattended unless there is a specific physician's order for self-administration, which was not present for any of the residents involved. Additionally, one resident was found with a medication cup containing gummies identified as vitamin/supplement products, for which there was no physician's order documented. The LPN confirmed the nature of the gummies and the absence of a doctor's order. The Director of Nursing acknowledged that none of the residents had been assessed for self-administration of medications, and that medications should not have been left with the residents. These actions and inactions resulted in the facility not following its own medication administration policy and failing to ensure medications were administered and consumed as ordered.