Medications Improperly Left at Bedside for Self-Administration
Penalty
Summary
The facility failed to ensure the proper and safe administration of medications in accordance with its own policy for two residents. In the first instance, a resident with diagnoses including bradycardia, heart failure, hypertension, and diabetes was found to have medications left at her bedside without her knowledge. The resident, who was cognitively intact, reported that nurses frequently left her medications at her bedside because she was difficult to wake in the mornings. On one occasion, an adult protective specialist visiting the resident observed a medicine cup with medications left on the resident's assistive device chair cushion. The nurse responsible for administering the medications documented them as given but did not recall leaving them at the bedside, despite the resident's statement and the observation by the visitor. In the second case, another resident with Alzheimer's disease and moderate cognitive impairment reported that nurses left her morning medications on her bedside table, and she would take them at her convenience. During an interview, the resident confirmed that her medications were currently sitting on her bedside table, and this was observed by surveyors. The LPN who delivered the medications admitted to leaving them on the bedside table and was unaware of any policy prohibiting this practice. The resident's care plan did not include self-administration of medications as a goal or focus area. Facility policy requires that medications be administered safely by licensed nurses at the specified time, following recommended methods, and that staff ensure medications are swallowed before leaving the resident. Both the DON and the Administrator confirmed that medications should not be left at the bedside and that staff are expected to follow policy and procedures. The failure to administer medications as required and leaving them at the bedside for residents to take on their own constituted a deficiency in pharmaceutical services.