Unattended Medication Left at Nurses' Station
Penalty
Summary
A deficiency occurred when a nurse prepared a dose of miralax mixed in water for a resident during a morning medication pass and left the unlabeled cup on top of the medication cart. When the resident was unavailable to take the medication, the nurse placed the cup containing miralax on the counter at the nurses' station and left it unattended. The cup, which appeared to be a regular cup of water, remained on the counter for an extended period without supervision, during which time several residents, including one who walked behind the nurses' station and touched items on the counter, passed by the unattended medication. Interviews with the nurse, unit manager, and DON confirmed that medications should not be left unattended or unlabeled, and that staff should not taste medication to identify it. The nurse admitted to leaving the miralax unattended and to tasting the contents to confirm its identity after the surveyor pointed it out. The unit manager noted that residents on the unit have dementia and may wander, increasing the risk of accidental ingestion. The DON reiterated that medications must be stored securely and not left accessible to residents or staff.