Medications Left Unattended; Nurse Failed to Ensure Ingestion
Penalty
Summary
A deficiency occurred when a nurse failed to ensure a resident swallowed their prescribed medications during medication administration. The resident, who was moderately cognitively impaired and had diagnoses including diabetes and congestive heart failure, was observed with a medication cup containing nine pills left on her overbed table. The resident was unable to identify the medications or the reason they were present. The nurse responsible for administering the medications reported that she had an urgent need to use the bathroom and left the medications with the resident, without confirming ingestion. The nurse had documented the medications as administered in the medication administration record, despite not witnessing the resident take them. Interviews with facility leadership confirmed that the nurse did not follow expected procedures, which require staff to observe residents swallowing their medications and prohibit leaving medications at the bedside. The nurse acknowledged that the resident may have spit out the pills after initially putting them in her mouth. Both the DON and the Administrator stated that the nurse's actions did not align with facility policy or professional standards for medication administration.