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F0658
D

Unattended Medication Left at Bedside Without Physician Order

San Rafael, California Survey Completed on 05-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A licensed nurse left a cup containing nine pills on a resident's bedside table, unattended, without a physician's order for self-administration. The resident, who had hemiplegia and hemiparesis following cerebrovascular disease but no memory impairment, reported that the nurse left the medications for her to take but noted that one of her prescribed medications was missing. Observation confirmed the unattended medications, and the nurse acknowledged leaving them at the bedside. The Director of Staff Development confirmed that facility policy prohibits leaving medications unattended at a resident's bedside without a physician's order, and that no residents, including the one involved, had such an order. Facility policy and the job description for licensed nurses both require that medications be administered according to established standards and only with proper authorization for self-administration.

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