Unsecured Medication Left at Bedside
Penalty
Summary
A deficiency occurred when prescription medication was found unsecured at a resident's bedside during a morning medication pass. An LPN discovered a cup containing two pills (Faxiga and Levothyroxine) on the resident's bedside table, with no knowledge of who placed them there. The resident, who has a history of chronic obstructive pulmonary disease, dementia, psychotic disorder, schizoaffective disorder, major depressive disorder, type two diabetes mellitus, and generalized anxiety, was observed reaching for the medication and stated that pills are often left at the bedside because staff claim they cannot wake her up. The resident's records indicated moderately impaired cognition and no completed self-administration assessment. Facility policy requires all medications to be stored in locked compartments or under the direct observation of the person administering them. The DON confirmed that leaving medication at the bedside is unsafe and against facility policy, as it could allow unauthorized access. The medication in question was scheduled for administration at 6 a.m. and should not have been left unattended at the resident's bedside.
Plan Of Correction
F 761 Medication Storage ELEMENT #1: Medication was removed and properly disposed of from Resident #21's room. ELEMENT #2: Current residents have the potential to be affected by the deficient practice. Current residents' rooms were evaluated for proper medication storage. Any medications not properly stored were properly stored and/or disposed of. ELEMENT #3: The policy, Medication and Treatment Cart Storage policy, was reviewed and deemed appropriate. The policy remains in place. Licensed Practical Nurses & Registered Nurses were re-educated on the policy, Medication and Treatment Cart Storage, with emphasis on proper medication storage. ELEMENT #4: The Director of Nursing and/or designee will conduct random audits of 5 residents' rooms to ensure substantial compliance with medication storage. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025