Medication Left Unsecured at Bedside in Dementia Unit
Penalty
Summary
A deficiency occurred when a medication cup containing Biofreeze gel was found left unattended on a resident's nightstand in a dementia unit. The resident, who had severe cognitive impairment and diagnoses including Alzheimer's disease and low back pain, was not assessed or authorized for self-administration of medication. Facility policy required medications to be stored safely and not left at the bedside unless the resident was assessed as appropriate for self-administration and a physician's order was obtained. The medication was observed by a surveyor, and staff interviews confirmed that medications should not be left at the bedside, especially in a unit with residents who wander. An LPN acknowledged placing the medication in the resident's room and admitted that it should not have been left there, expressing uncertainty about who left it on the nightstand. The Director of Health Services and Executive Director both confirmed that facility policy prohibits leaving medications at the bedside under these circumstances. Other staff interviewed stated they would have removed the medication if they had seen it. The incident demonstrated a failure to secure medications and provide adequate supervision to prevent potential accidents, as required by facility policy.