Medications Left Unsecured at Bedside Without Self-Administration Assessment
Penalty
Summary
Nursing staff failed to ensure that medications were properly secured and administered according to facility policy and professional standards. In two separate cases, nurses left medications at the bedside of residents who had not been assessed for self-administration. One resident, who was cognitively intact but had no documented assessment for self-administration, was observed with a medication cup containing multiple pills and a cup of water on his bedside table. The resident confirmed that the nurse routinely left his pills for him to take, and he self-administered the medication during the observation. The assigned nurse initially believed the resident was assessed for self-administration but later admitted she had not witnessed the resident take the medication and acknowledged she should have stayed to observe ingestion. In another instance, a cognitively intact resident was found with a medication cup containing five pills and another cup with liquid medication on his bedside table. The resident reported that a nurse had given him the medications and was impatient, repeatedly urging him to take them. Medication administration records did not show that this nurse had administered medications to the resident in the past 30 days. Further review indicated that the resident's scheduled medications matched the pills found at the bedside, and interviews with multiple nurses revealed confusion about who had left the medications. None of the nurses involved could confirm that the resident had been assessed for self-administration, and the medical director confirmed that such an assessment had not been completed. Both the Director of Nursing and the Administrator stated that facility policy requires nurses to observe residents taking their medications unless a formal assessment for self-administration has been completed. In both cases, medications were left at the bedside without such assessments, and the responsible staff could not provide a clear explanation for this deviation from protocol.