Unsecured Medication Left at Bedside Without Self-Administration Assessment
Penalty
Summary
A resident was observed taking multiple pills from a medicine cup that had been left on his overbed table by nursing staff. The resident confirmed that these were his morning medications and that, while it did not happen often, medications were sometimes left for him to take later. The medications included Aspirin, Atorvastatin, Clopidogrel Bisulfate, Glipizide, Jardiance, Meloxicam, and Sodium Chloride. The resident had a BIMS score indicating intact cognition, but there was no physician's order or assessment authorizing self-administration of medications, nor was there a care plan in place for self-administration. Facility staff interviews revealed that the nurse responsible became distracted and left the medications at the bedside, contrary to standard procedures. The Assistant Director of Nursing acknowledged that while there was a policy for self-administration, no formal assessment was conducted to determine the resident's capability, relying instead on BIMS scores and staff familiarity. The facility's policy requires an assessment of mental and physical abilities before allowing self-administration, but this was not followed in this case. The medications left unsecured were accessible to other residents as well.