Medications Left Unattended at Bedside Without Self-Administration Assessment
Penalty
Summary
A deficiency occurred when a resident, admitted with diagnoses including hypertension, congestive heart failure, and diabetes, was found with five pills in a medication cup left on the bedside table. The resident, who was cognitively intact and required varying levels of assistance for activities of daily living, reported that an LPN had left the medications at the bedside for self-administration. Observation and interview confirmed that the LPN left the room before ensuring the resident had taken the medications, despite the resident not being assessed or approved for self-administration. Further review of the clinical record and facility policy revealed that there was no completed self-administration assessment or evaluation for the resident. The facility's medication pass policy requires staff to observe residents until all medications are swallowed and prohibits leaving medications at the bedside. The LPN identified the medications left as trazodone, carvedilol, Ativan, and torsemide, and acknowledged that leaving them at the bedside was not in accordance with facility policy.