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F0689
D

Medications Improperly Left at Bedside for Two Residents

Concord, California Survey Completed on 04-18-2025

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

The facility failed to ensure that medications were properly stored and not left at the bedside for two residents, resulting in an accident hazard. Facility policy required that medications be administered safely and only allowed self-administration if the interdisciplinary team and physician determined it was appropriate, with medications stored securely. However, for both residents involved, there were no physician orders or care plan interventions permitting self-administration or bedside storage of medications. One resident, with a history of hypertension, COPD, cerebral aneurysm, and anemia, was observed on multiple occasions with a cup containing multiple pills at their bedside. The resident stated that staff gave them the pills but they were waiting to take them. The resident's care plan did not include self-administration, and the medication administration record showed that a nurse documented the medications as administered. The nurse later confirmed leaving the medications at the bedside at the resident's request, despite the resident not being assessed for self-administration. A second resident, with diagnoses including diabetes, chronic kidney disease, and cognitive decline, was also observed with a cup of pills at their bedside while they were in bed with their eyes closed. This resident's care plan and physician orders did not permit self-administration or bedside storage of medications. The nurse documented the medications as administered, but the medications were left at the bedside. Facility leadership confirmed that medications should not be left at the bedside and that the nurse was responsible for ensuring medications were taken as ordered.

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