Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
Nursing staff failed to ensure that medications were administered according to professional standards, resulting in medications being left at the bedside for three residents. One resident with a history of falling and intact cognition was found with a Zyrtec tablet on her bed, which she stated was given by the nurse, and she had not signed any form to self-administer her medications. Another resident with severe cognitive impairment was observed with a Vitamin D tablet left on her over bed table, and there was no documentation that she was permitted to self-administer medications. The LPN confirmed the pill matched the resident's prescribed medication and acknowledged it should not have been left in the room. A third resident, who had intact cognition and diagnoses including bipolar disorder and dysphagia, was observed keeping his Albuterol inhaler on his person and on his window seal. Nursing notes indicated that staff assisted the resident in accessing the inhaler, but there was no documented assessment authorizing the resident to self-administer this medication. Facility staff confirmed the lack of documentation for self-administration for all three residents involved.