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F0658
D

Medication Left Unattended at Bedside

San Rafael, California Survey Completed on 06-03-2025

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 deficiency occurred when a nurse left a whitish watery medication, intended for a resident with dysphagia who receives nutrition and medication via feeding tube, unattended on the resident's overbed table. The resident confirmed that the medication was left by the nurse and stated that staff sometimes leave medications at her bedside or overbed table. Observations confirmed the medication and a syringe were left unattended, and the nurse acknowledged that this was against facility policy due to safety concerns, especially given the presence of confused residents who wander and could access the medication. The Director of Staff Development verified that the medication was left unattended and confirmed it was a safety issue. Facility policy requires that medications, once removed from their packaging, should be administered safely or disposed of according to the medication destruction policy, and that bedside medication storage is only permitted when it does not present a risk to confused residents. The failure to follow these procedures resulted in the medication being left in a location accessible to unintended persons.

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