Medications Left Unattended at Bedside for Visually Impaired Resident
Penalty
Summary
A deficiency occurred when a nurse left a cup of oral medications and an insulin pen unsupervised on a resident's bedside dresser. The resident, who was legally blind and admitted with diagnoses including dependence on renal dialysis, Type 2 Diabetes Mellitus, and chronic pain, did not have a physician's order or care team review permitting self-administration of medications. The resident was assessed as cognitively intact but reported not self-administering medications and was unsure of the specific medications present, only assuming that his phosphorus binders were included. During observation, the nurse later returned to administer the medications and insulin, but the oral medications were not identified to the resident prior to administration. Interviews with nursing staff confirmed that medications should not be left unattended at the bedside, as this practice is considered unsafe and contrary to facility policy, which requires the seven rights of medication administration. The nurse involved acknowledged that leaving the medications was not standard practice and occurred because the resident requested filtered water before taking the pills. Other staff members reiterated that medications found at the bedside should be reported and properly disposed of, and that nurses are expected to ensure medications are swallowed before leaving the room.