Medications Left Unattended and at Bedside Without Assessment
Penalty
Summary
Facility staff failed to prevent potential accidents by leaving medications at the bedside of two residents without conducting self-administration assessments. One resident, who had diagnoses including cerebral infarction, type 2 diabetes, difficulty swallowing, hyperlipidemia, and hypertension, was found with a cup containing seven pills on his bedside table. The resident stated that the nurse left the medications for him to take, but he had not yet done so due to an upset stomach. Review of the resident's record confirmed that no self-administration assessment had been completed. In another instance, a rehabilitation resident with a history of malignant neoplasm of the larynx, constipation, and UTI was found with a bottle of Dulcolax in her purse, also without a self-administration assessment on file. Additionally, a registered nurse was observed leaving a cup containing blood pressure medication unattended on top of the medication cart during a medication pass. At the time, two unidentified residents were present in the hallway, creating the potential for unauthorized access to the medication. Facility policy requires that medications not be provided at bedside without a physician's order and approval by the interdisciplinary team and administration, which was not followed in these instances.