Failure to Secure and Properly Administer Medications
Penalty
Summary
Surveyors identified multiple instances where medications and biologicals were not properly stored or administered according to professional standards. In one case, a resident with severe cognitive impairment and a history of wandering was found to have a cup containing pudding with crushed medications left at the bedside from the previous night. The LPN confirmed that the medications had been left unattended in the resident's room, which was not in accordance with facility policy. Another nurse reported a similar incident in the past, where medications were left in a resident's room, and acknowledged that staff are required to observe residents taking their medications. For another resident with moderate cognitive impairment and multiple diagnoses, a cup containing several pills was observed left on the bedside table while staff were out of sight. The responsible RN initially stated the pills were left by night shift, then explained the resident became ill during medication pass, leading to the pills being left in the room. The RN had documented in the MAR that all medications were administered, but could not identify which medications were left in the cup. The resident confirmed that staff regularly left medications at the bedside and left the room. A third resident was found asleep with a medicine cup containing multiple pills on the bedside table. The LPN admitted she had not administered the pills yet and intended to return later. The resident did not have an order for self-administration of medication. Additionally, surveyors observed loose pills and a vial of inhalation medication stored outside their original containers in a medication cart, which was confirmed by the LPN to be improper storage. Facility policy requires medications to be stored in their original packaging and in an orderly manner.