Failure to Prevent Accident Hazards Due to Unmonitored Bedside Medications
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards for a resident who had a history of low back pain and a recent surgery with an incision. The resident was admitted with a prescription for acetaminophen (Tylenol) to be administered as needed, with a maximum daily dosage specified, but there was no documented order allowing the medication to be kept at the bedside. Observations over several days revealed that both Tylenol and bacitracin zinc ointment were present on the resident's bedside table. The resident reported self-administering both medications daily without staff monitoring and stated that staff had not discussed self-administration or the need for nurse oversight. Interviews with nursing staff and facility leadership confirmed that medications should not be left at a resident's bedside without a physician's order and an assessment to determine safety. Staff also indicated that Tylenol usage should be monitored for side effects and dosage limits, and that any medications found at the bedside should be reported to nursing staff. Despite these expectations, the medications remained accessible to the resident without appropriate assessment or monitoring, constituting a failure to prevent accident hazards and ensure adequate supervision.