Failure to Observe Medication Administration and Unauthorized Bedside Medication Placement
Penalty
Summary
Licensed nursing staff failed to ensure that residents consumed prescribed medications prepared for them before leaving their rooms. In two cases, medications were left at the bedside of residents who had not been assessed or authorized to self-administer their medications. One resident, with diagnoses including adult failure to thrive, anemia, and atrial fibrillation, was observed receiving medications prepared by an LPN, who then left the medication cup on the bedside table and exited the room without confirming ingestion. The clinical record did not indicate that this resident was assessed for self-administration of oral medications. Another resident, with a history of anxiety disorder, chronic pain, and a parathyroid gland neoplasm, also had medications left at the bedside on multiple occasions. In one instance, the LPN left the medications at the bedside while the resident's family was visiting, assuming the family would ensure the medications were taken. The family later reported the incident, and the LPN acknowledged the error. In a separate incident, another LPN left medications at the bedside because the resident previously refused to take them in her presence, intending to return later to check if they had been taken. The clinical record did not show that this resident was authorized for self-administration. Facility policy and inservice education clearly stated that medications should not be left at the bedside unless a resident is assessed and authorized to self-administer. Both LPNs involved acknowledged awareness of this policy and had received relevant education. Despite this, medications were left unattended at the bedside, and the required observation of medication consumption was not performed.