Failure to Provide Adequate Supervision and Safe Medication Management
Penalty
Summary
Facility staff failed to provide adequate supervision and safe care during activities of daily living for a resident with significant medical needs, including respiratory failure, heart failure, a vertebral fracture, hospice care, and dementia. The resident required extensive assistance from two staff members for repositioning in bed, as documented in the MDS assessment. However, a Geriatric Nursing Assistant provided care alone and left the resident unattended on her side in bed to retrieve supplies. During this absence, the resident fell from the bed and sustained a fracture to the left superior pubic ramus. The incident was confirmed by facility records and staff interviews, and the administrator acknowledged that staff did not follow the facility's ADL policy for supervision. Additionally, another resident was found to have multiple medications, including medicated spray, Desitin, Pepto Bismol, and cough syrup, stored openly at the bedside. The resident reported keeping these medications because staff would not provide them, and a family member supplied them. Facility policy prohibits residents from having medications at the bedside, and the DON was unaware of the situation until it was observed. Social Services staff and the attending physician confirmed that the resident had a history of keeping medications in the room and that self-administration was considered unsafe due to concerns about overuse. Despite these concerns, staff continued to allow the resident to keep and self-administer the medications.