Medications Left Unattended and Not Administered per Professional Standards
Penalty
Summary
A deficiency occurred when a resident, who was alert and oriented, was observed taking an oral medication without staff supervision. The resident was found lying in bed with a white oval pill on a napkin on the overbed table. The resident picked up the pill and swallowed it without a nurse present. Upon questioning, the resident stated she had taken about 13 pills and that the nurse did not stay with her while she took the last few. The nurse involved admitted to leaving the resident unattended, assuming the medications were being taken as she walked away. A review of the resident's electronic health record revealed that no self-medication administration evaluation had been completed for this resident. Facility policy required staff to observe residents ingest medications and not to leave medications at the bedside unless the resident had approval for self-administration, which was not the case here. Both the Resident Care Manager and the Chief Nursing Officer confirmed that medications should not be left at the bedside and that staff are expected to observe residents taking all medications.