Medications Left Unattended at Bedside for Resident with Cognitive Impairment
Penalty
Summary
A licensed vocational nurse (LVN) left four prescribed medications at the bedside of a resident who had diagnoses including end stage renal disease, hemodialysis, and dementia. The resident had fluctuating capacity to understand and make decisions, as documented in the history and physical, and required moderate assistance with personal care tasks according to the Minimum Data Set. The resident reported that the nurse left the medications at his request during the morning medication pass, and the medications remained at the bedside for over two hours. Interviews with nursing staff, including the LVN, a registered nurse (RN), and the director of nursing (DON), confirmed that facility policy and standard practice require nurses to remain with residents until all medications are taken, and that medications should not be left unattended at the bedside. The DON and RN both stated that the resident was not considered safe to self-administer medications. Review of facility policies indicated that standards of practice are intended to ensure safe and effective care, and that quality of care is governed by regulations focused on resident well-being and safety.