Medications Left at Bedside Without Assessment or Order
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by not ensuring that staff followed policy regarding medication administration. Specifically, a registered nurse left multiple medications on a paper towel at a resident's bedside, despite facility policy requiring staff to remain with the resident while medication is swallowed and prohibiting leaving medications in a resident's room without proper orders. The nurse indicated she had been told by other staff that it was acceptable to leave medications at this resident's bedside, but she was unsure if the resident had been assessed for self-administration or had a physician's order permitting this practice. The resident involved had a history of dementia with mood disturbance, late onset Alzheimer's disease, chronic diastolic congestive heart failure, anemia, recurrent major depressive disorder, essential hypertension, and dorsalgia. The resident's most recent assessment indicated moderate cognitive impairment, and the care plan noted confusion and impaired short-term memory, with no indication that the resident was to self-administer medications. During observation, the resident was unable to identify the medications or their purposes and stated that medications were left in the room every morning for them to take. Interviews with facility staff, including the RN, RN Regional Clinician, Director of Nursing, and Administrator, confirmed that there was no assessment or physician's order for the resident to self-administer medications. Staff acknowledged that leaving medications at the bedside was against facility policy and standard practice, especially for residents lacking the capacity for self-administration. The incident was attributed to poor judgment and a lack of adherence to established medication administration protocols.